A Qualitative Analysis of Burn Injury Patient and Caregiver Experiences in Kwazulu-Natal, South Africa: Enduring the Transition to a Post-Burn Life

Over 95% of fire-related burns occur in low- and middle-income countries (LMICs), an important and frequently overlooked global health disparity, yet research is limited from LMICs on how survivors and their caregivers recover and successfully return to their pre-burn lives. This study examines the lived experiences of burn patients and caregivers, the most challenging aspects of their recoveries, and factors that have assisted in recovery. This qualitative study was conducted in KwaZulu-Natal, South Africa at a 900-bed district hospital. Participants (n = 35) included burn patients (n = 13) and caregivers (n = 22) after discharge. In-depth interviews addressed the recovery process after a burn injury. Data were coded using NVivo 12. Analysis revealed three major thematic categories. Coded data were triangulated to analyze caregiver and patient perspectives jointly. The participants’ lived experiences fell into three main categories: (1) psychological impacts of the burn, (2) enduring the transition into daily life, and (3) reflections on difficulties survivors face in returning for aftercare. The most notable discussions regarded stigma, difficulty accepting self-image, loss of relationships, returning to work, and barriers in receiving long-term aftercare at the hospital outpatient clinic. Patients and caregivers face significant adversities integrating into society. This study highlights areas in which burn survivors may benefit from assistance to inform future interventions and international health policy.

An assessment of human resource distribution for public eye health services in KwaZulu-Natal, South Africa

Background: The development of human resources for eye health (HReH), aimed at achieving a 25% reduction in visual impairment by the year 2020, was one of the VISION 2020 objectives.

Aim: To assess HReH in the public sector of KwaZulu-Natal (KZN), and its effect on the accessibility of eye care in the province.

Setting: All public eye facilities in KZN.

Methods: A quantitative cross-sectional study using a close-ended questionnaire to assess distribution and outputs of HReH. At the end of the questionnaire, respondents gave general comments on their ability to provide services.

Results: Human resource rates were 0.89 for ophthalmologists, 2.44 for cataract surgeons, 4.8 for optometrists and 4.7 for ophthalmic nurses per 1 million population. Most health facilities had some HReH working in them, albeit none had dispensing opticians. Regression analysis showed that 67.1% of variation in cataract surgery was because of the number of surgeons available. Cataract surgical rates were low with a waiting period of up to 18 months. In addition to the refractive error regression analysis of 33.7%, spectacle supply was low, with a backlog of up to 9 months in some facilities.

Conclusion: Overall, HReH targets as per VISION 2020 and the National Prevention of Blindness have not been met in this region. Dispensing opticians are not employed in any of the province’s health districts. An increase in the eye health workforce is necessary to improve the eye health outcomes for people dependent on public eye facilities.

Survival of south african women with breast cancer receiving anti-retroviral therapy for HIV

Breast cancer outcomes in sub-Saharan Africa is reported to be poor, with an estimated five-year survival of 50% when compared to almost 90% in high-income countries. Although several studies have looked at the effect of HIV in breast cancer survival, the effect of ARTs has not been well elucidated.

All females newly diagnosed with invasive breast cancer from May 2015–September 2017 at Charlotte Maxeke Johannesburg Academic and Chris Hani Baragwanath Academic Hospital were enrolled. We analysed overall survival and disease-free survival, comparing HIV positive and negative patients. Kaplan-Meier survival curves were generated with p-values calculated using a log-rank test of equality while hazard ratios and their 95% confidence intervals (CIs) were estimated using Cox regression models.

Of 1019 patients enrolled, 22% were HIV positive. The overall survival (95% CI) was 53.5% (50.1–56.7%) with a disease-free survival of 55.8% (52.1–59.3) after 4 years of follow up. HIV infection was associated with worse overall survival (HR (95% CI): 1.50 (1.22–1.85), p < 0.001) and disease-free survival (OR (95% CI):2.63 (1.71–4.03), p < 0.001), especially among those not on ART at the time of breast cancer diagnosis. Advanced stage of the disease and hormone-receptor negative breast cancer subtypes were also associated with poor survival. Conclusion HIV infection was associated with worse overall and disease-free survival. HIV patients on ARTs had favourable overall and disease-free survival and with ARTs now being made accessible to all the outcome of women with HIV and breast cancer is expected to improve.

The implementation of a national paediatric oncology protocol for neuroblastoma in South Africa

The aim of the World Health Organization-International Paediatric Oncology Society is to improve childhood cancer survival in low- and middle-income countries to 60% by 2030. This can be achieved using standardised evidence-based national treatment protocols for common childhood cancers. The aim of the study was to describe the development and implementation of the SACCSG NB-2017 neuroblastoma (NB) treatment protocol as part of the treatment harmonisation process of the South African Children’s Cancer Study Group.

The Consolidated Framework for Implementation Research was used to identify factors that could influence the implementation of the national NB protocol as a health care intervention. The evaluation was done according to five interactive domains for implementation: intervention characteristics, inner setting, outer setting, individual or team characteristics and the implementation process.

The protocol was developed over 26 months by 26 physicians involved in childhood cancer management. The process included an organisational phase, a resource identification phase, a development phase and a research ethics approval phase. Challenges included nationalised inertia, variable research ethical approval procedures with delays and uncoordinated clinical trial implementation.

The implementation of the national NB protocol demonstrated the complexity of the implementation of a national childhood cancer treatment protocol. However, standardised paediatric cancer treatment protocols based on local expertise and resources in limited settings are feasib

District hospital surgical capacity in Western Cape Province, South Africa: A cross-sectional survey

Background. The role of the district hospital (DH) in surgical care has been undervalued. However, decentralised surgical services at DHs have been identified as a key component of universal health coverage. Surgical capacity at DHs in Western Cape (WC) Province, South Africa, has not been described.

Objectives. To describe DH surgical capacity in WC and identify barriers to scaling up surgical capacity at these facilities.

Methods. This was a cross-sectional survey of 33 DHs using the World Health Organization surgical situational analysis tool administered to hospital staff from June to December 2019. The survey addressed the following domains: general services and financing; service delivery and surgical volume; surgical workforce; hospital and operating theatre (OT) infrastructure, equipment and medication; and barriers to scaling up surgical care.

Results. Seven of 33 DHs (21%) did not have a functional OT. Of the 28 World Bank DH procedures, small WC DHs performed up to 22 (79%) and medium/large DHs up to 26 (93%). Only medium/large DHs performed all three bellwether procedures. Five DHs (15%) had a full-time surgeon, anaesthetist or obstetrician (SAO). Of DHs without any SAO specialists, 14 (50%) had family physicians (FPs). These DHs performed more operative procedures than those without FPs (p=0.005). Lack of finances dedicated for surgical care and lack of surgical providers were the most reported barriers to providing and expanding surgical services.

Conclusions. WC DH surgical capacity varied by hospital size. However, FPs could play an essential role in surgery at DHs with appropriate training, oversight and support from SAO specialists. Strategies to scale up surgical capacity include dedicated financial and human resources.

Inequity in paediatric oncology in South Africa – The neuroblastoma case study

Background: The South African Constitution affords everyone the right to access healthcare services, but in children the care must ensure survival.

Aim: This study aimed to determine whether there was access to equitable paediatric oncology services for the management of neuroblastoma in South Africa.

Setting: Paediatric oncology services in South Africa between 2000 to 2014.

Methods: A literature review was carried out, focussing on access to healthcare in South Africa for children with neuroblastoma. Services were classified in accordance with the International Society of Paediatric Oncology resource settings for neuroblastoma diagnosis. Supplementary data from a retrospective study of the management of neuroblastoma in South Africa were evaluated.

Results: The neuroblastoma care services in South Africa were not uniformly resourced and accessible across the provinces. Two provinces (2/9 provinces) had excellent healthcare services that included access to transplant facilities, whilst three (3/9 provinces) had no services. Traveling distances to healthcare services pose major challenges, whilst number of medical staff providing oncology care were unequally distributed. The Constitution did not define basic healthcare for children, nor did the National Cancer Control plan acknowledge childhood cancer as a defined entity without provision until 2022.

Conclusion: Children diagnosed with neuroblastoma do not have equitable access to healthcare as stated in the South African Constitution. The case of neuroblastoma highlights the inequitable access to childhood care as a whole in South Africa. As the health of children is a national priority, it is therefore necessary to sensitise policymakers to the needs of children with cancer.

Clavien–Dindo classification of post-operative complications in a South African setting

Background: Clavien-Dindo (CD) classification is used to standardize the reporting of post-operative complications. The aim of the study was to report our initial experience following the adoption of the use of CD classification for reporting of post-operative complications across surgical specialities. Methods: An audit of prospectively collected data, from records of patients aged 18 years and older who had surgery, was conducted. Data collected included patients’ demographics, acuity of operations, types of surgery, recorded post-operative complications and assigned CD class. Categorical variables were summarized using frequency and percentages. The mean with standard deviation (SD) was used for the aggregation of continuous data. χ2-test or Fisher’s exact test was used to compare categorical findings. The strength of associations was measured using Cramer’s V and the φ coeficient. Data analysis was carried out using the SAS version 9.4 for Windows. The level of significance was set at a P value below 0.05. Results: A total of 3399 surgical procedures were performed, of which 1700 (50.0%) were emergencies. The mean (± SD) age of operated patients was 44.3 (±16.7) years. eThre were 11.2% post-operative complications of which 65.8% were directly related to surgical procedures. Approximately 48.1% of the complications were infections. The CD classicfiation was applied to the complications, of which 31.6% were categorized as Grade I and 26.3% as Grade IIIb. There was a significant but weak association between reported complication types and surgical specialty (P < 0.0001; Cramer's V = 0.25), and between the reported grade of complications and surgical specialty (P < 0.0001; Cramer's V = 0.21). Overall mortality was 7.7%. Conclusions: The CD classification was adopted by all specialties studied. The rate of post-operative complications was 11%, the majority of which were infections. Reported grades of complications were influenced by surgical specialty. A high number of Grade IIIb complications were recorded than have been previously reported.

Long-term mortality after lower extremity amputation: A retrospective study at a second-level government hospital in Cape Town, South Africa

Long-term mortality after lower extremity amputation (LEA) is not well reported in low- and middle-income countries. The primary aim of this study was to report 30-day and one-year mortality after LEA in South Africa. The secondary objective was to report risk factors for one-year mortality.
This was a retrospective study of patients undergoing LEA at New Somerset Hospital, a second-level government facility in Cape Town, South Africa from October 1, 2015 to October 31, 2016. A medical record review was undertaken to identify co-morbidities, operation details, and perioperative mortality rate. Outcome status was defined as alive, dead, or lost to follow-up. Outcomes at 30 days and one-year were reported.
There were 152 patients; 90 (59%) males and the median age was 60 years. Co-morbidities were available for 137 (90%). One hundred and eight (79%) had peripheral vascular disease and 91 (66%) had diabetes mellitus. Fifty-three (35%) had more than one LEA on the same or contralateral limb. There were 183 LEAs in 152 patients. The most common LEA was above knee amputation (n=104, 57%) followed by below-knee amputation (n=36, 20%). At 30 days, 102 (67%) of 152 were traced and 12 (12%) were dead. At one year, 86 (57%) were traced and 37 (43%) were dead.
At this second-level South African hospital, 43% of patients undergoing LEA were dead after one year. In resource-constrained settings, mortality data are necessary when considering resource allocation for LEA and essential surgical care packages.

Quality of Histopathological Reporting in Breast Cancer: Results From Four South African Breast Units

High-quality histopathology reporting forms the basis for treatment decisions. The quality indicator for pathology reports from the European Society of Breast Cancer Specialists was applied to a cohort from four South African breast units.

The study included 1,850 patients with invasive breast cancer and evaluated 1,850 core biopsies and 1,158 surgical specimen reports with cross-center comparisons. A core biopsy report required histologic type; tumor grade; and estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) status, with a confirmatory test for equivocal HER2 results. Ki-67 was regarded as optional. Pathologic stage, tumor size, lymphovascular invasion, and distance to nearest invasive margin were mandatory for surgical specimens. Specimen turnaround time (TAT) was added as a locally relevant indicator.

Seventy-five percent of core biopsy and 74.3% of surgical specimen reports were complete but showed large variability across study sites. The most common reason for an incomplete core biopsy report was missing tumor grade (17.9%). Half of the equivocal HER2 results lacked confirmatory testing (50.6%). Ki-67 was reported in 89.3%. For surgical specimens, the closest surgical margin was reported in 78.1% and lymphovascular invasion in 84.8% of patients. Mean TAT was 11.9 days (standard deviation [SD], 10.8 days) for core biopsies and 16.1 days (SD, 11.3) for surgical specimens.

Histopathology reporting is at a high level but can be improved, especially for tumor grade, HER2, and Ki-67, as is reporting of margins and lymphovascular invasion. A South African pathology consensus will reduce variability among laboratories. Routine use of standardized data sheets with synoptic reports and ongoing audits will improve completeness of reports over time.

Clinical quality and performance measurement in the prehospital emergency medical services in the low-to-middle income country setting

Measuring quality and safety in any healthcare setting however is highly contextual, and depends on the manner in which quality is defined or viewed within that setting. It is this contextual nature that has provoked significant debate and hindered efforts at developing formal standards or criteria for measuring quality and safety in healthcare, regardless of setting. Historically, performance within the Emergency Medical Services (EMS) delivering prehospital emergency care has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes.
The overall aim of the research was to develop a framework for clinical quality and performance-based assessment of prehospital emergency care for use in the South African EMS.
The research was divided amongst four studies, with each study constituting one of the overall research objectives. Study I was a sequential explanatory mixed methods study with the aim of understanding the knowledge, attitudes and practices of clinical quality and performance assessment amongst South African EMS personnel. Part 1 consisted of a webbased cross-sectional survey, and Part 2 consisted of semi-structured telephonic interviews of select participants from Part 1 to explore the results of the survey. Descriptive statistics were carried out to summarise and present all survey items, and conventional content analysis employed to analyse the interview data. Study II utilised a three round modified Delphi study to identify, refine and review a list of appropriate quality indicators for potential use in the South African EMS setting. For Study III a novel quality indicator appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of their consensus application, and tested against the outcomes of Study II. Descriptive statistics were utilised to describe and summarize the categorical based appraisal data. Inter-rater reliability was calculated using percentage agreement and Gwet’s AC1. Correlation between the individual methods and the protocol was calculated using Spearman’s rank Correlation and z-test. Conventional content analysis was utilised to analyse the group discussions. Study IV utilised a multiple exploratory case study design to evaluate the current state of quality systems in the South African EMS. A formative assessment was conducted on the quality systems of four provincial EMS and one national private EMS, following which semi-structured interviews were conducted to further explore the results obtained from the formative assessment, supported by multiple
secondary data sources. Descriptive statistics were utilised to describe and summarize the formative assessment. Conventional content analysis was utilised to analyse the interview data and document analysis utilised to sort and analyse the supporting data
Despite relatively poor knowledge of organisational-specific quality systems, understanding of the core components and importance of quality systems was demonstrated. The role of these systems in the Low to Middle Income Country setting (LMICs) was supported by participants, where the importance of context, system transparency, reliability and validity were essential towards achieving ongoing success and utilisation. The role of leadership and communication towards the effective facilitation of such a system was equally identified. Participating services generally scored higher for structure and planning. Measurement and improvement were found to be more dependent on utilisation and perceived mandate. There was a relatively strong focus on clinical quality assessment within the private service, whereas in the provincial systems, measures were exclusively restricted to call times with little focus on clinical care. Staff engagement and programme evaluation were generally among the lowest scores. A multitude of contextual factors were identified that affected the effectiveness of quality systems, centred around leadership, vision and mission, and quality system infrastructure and capacity, guided by the need for comprehensive yet pragmatic strategic policies and standards. A total, 104 quality indicators reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n=13 QIs; 14%); out-of-hospital cardiac arrest (n=13 QIs; 14%); and acute coronary syndromes (n=11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%). There was mixed inter-rater reliability of the individual methods. There was similarly poor to moderate correlation of the results obtained between the individual methods (Spearman’s rank correlation=0.42,p<0.001). From a series of 104 QIs, 11 were identified that were shared between the individual methods. A further 19 QIs were identified and not shared by each method, highlighting the benefits of a multimethod approach.
For the purposes of this study we focused on the technical competence aspect of quality, in developing our measurement framework. Towards this, we identified a significant number of QIs assessed to be valid and feasible for the South African prehospital emergency care setting. The majority of which are centred around clinically focused processes of care, measures that are lacking in current performance assessment in EMS in South Africa. However, we also discovered the importance and influencing role of the individual practitioners and quality system in which the QIs will be implemented, a point highlighted across all the methodologies and studies. Given the potential magnitude of this influence, it is of the utmost importance that any measurement framework examining technicalquality, have equal in-depth understanding of these factors in order to be successful.