Reorganisation of primary care services during covid-19 in the western cape, south africa: Perspectives of primary care nurses

South African Family Practice, Volume 63, No. 1, Year 2021

Interpretação

Background: Primary care nurses play a pivotal role in the response to disasters and pandemics. The coronavirus diseases 2019 (COVID-19) pandemic required preventative, diagnostic, and curative measures for persons presenting with symptoms of COVID-19 by healthcare providers, whilst continuing other essential services. We aimed to investigate the reorganisation of primary care services during COVID-19 from the perspectives of primary care nurses in the Western Cape province of South Africa. Methods: We administered an online survey with closed and open-ended questions to professional nurses enrolled for a Postgraduate Diploma in Primary Care Nursing at Stellenbosch University (2020) and alumni (2017–2019) working in the Western Cape. Eighty-three participants completed the questionnaire. Results: The majority of the participants (74.4%) reported that they were reorganising services using a multitude of initiatives in response to the diverse infrastructure, logistics and services of the various healthcare facilities. Despite this, 48.2% of the participants expressed concerns, which mainly related to possible non-adherence of patients with chronic conditions, the lack of promotive and preventative services, challenges with facility infrastructure, and staff time devoted to triage and screening. More than half of the participants (57.8%) indicated that other services were affected by COVID-19, whilst 44.6% indicated that these services were worse than before. Conclusion: Our findings suggest that the very necessary reorganisation of services that took place at the start of the COVID-19 pandemic in South Africa enabled effective management of patients infected with COVID-19. However, the reorganisation of services may have longer-term consequences for primary care services in terms of lack of care for patients with other conditions, as well as preventive and promotive care. An exploratory-descriptive quantitative study was undertaken. The online survey was sent to Stellenbosch University’s Postgraduate Diploma in Primary Care Nursing students and alumni. This postgraduate diploma in Primary Care Nursing prepares nurses to assess, diagnose and manage a range of conditions in PHC settings. Admission criteria for a postgraduate diploma include at least two years of experience as a professional nurse. Students from various geographical locations in the Western Cape attend training at Stellenbosch University. The researchers had access to the contact details of these students and alumni, and they were therefore the accessible population for a rapid assessment at the time of the study which was conducted during the peak of the first wave of COVID-19 pandemic. The Western Cape province of South Africa is one of nine provinces and has a population of about 6.6 million people of which 64% reside in the City of Cape Town urban district. Three quarters (75.2%) of people in the province utilise PHC services.21 During 2019/2020, the Western Cape Department of Health reported 14.3 million PC encounters.21 The Western Cape has the highest life expectancy (68 years vs. 64 years on average for South Africa) and lowest maternal mortality rate (68.3 per 100 000 live births vs an average of 119 per 100 000 live births in South Africa) in the country.21 The three core services of the PHC platform in the Western Cape include: community-based care (via non-profit organisations and community health workers), PC (in 266 fixed and non-fixed facilities) and intermediate care. Primary care is driven by PC nurses and includes a range of services, including child and adult curative services, preventative services, women’s health, mental health, human immunodeficiency virus (HIV), tuberculosis (TB), and chronic disease management.21 The Postgraduate Diploma in Primary Care Nursing students and alumni that was the target population for this study also provide these services. Primary care nurses include professional nurses with undergraduate diplomas and degrees working in PHC settings as well as those who have completed an additional Postgraduate Diploma in Primary Care Nursing (Clinical Nurse Practitioners) that enables them to assess, diagnose, prescribe treatment for, and manage persons according to the PC guidelines.21 We developed a questionnaire based on the Impact of COVID-19 on the Nursing and Midwifery Workforce study (ICON) questions22 and other relevant literature. The questionnaire was based on the structures and processes needed for preparedness for COVID-19 and included: demographic information, COVID-19 training and attitudes, access to guidelines, facilities and equipment, services reorganisation, information, and training needs and personal or self-care needs. The questionnaire was reviewed by four external experts, including two nursing health services managers, one academic involved in the COVID-19 response in the Western Cape, and one expert working for a non-governmental organisation involved in community education and testing in relation to COVID-19. The experts suggested some changes to a few questions, as well as some additional questions, but were overall happy with the content of the questionnaire. The final questionnaire comprised of 48 questions, both closed- and open-ended. Open-ended questions allowed for participants to provide explanations or comments regarding their context that may have not been captured by closed-ended questions. For this article, we focused on the questions related to services reorganisation. Validity was ensured by developing the questionnaire from the literature and subjecting it to expert review. Reliability analysis could only be performed on the questions that measured similar concepts on a Likert-type scale. These questions related to confidence and preparedness (Cronbach alpha 0.7) and personal and self-care needs, specifically worry and anxiety (Cronbach alpha 0.75). Professional nurses enrolled for the Postgraduate Diploma in Primary Care Nursing (year 2020) and alumni from the years 2017–2019 were included (n = 251). We excluded nurses who were not working in PHC practice at the time of the study or who did not have working emails (n = 37). The total number of eligible participants was 214. We included the total population in the sample to account for non-responders. A minimum sample size 136 was needed for representativeness.23 A pilot survey was conducted to assess whether the questions were clear for participants and if they could easily follow the electronic link and complete the online questionnaire. We selected 20 students from the 2016 cohort of which 12 completed the questionnaire. We made a few adjustments to some questions and did not include the pilot data in the main study. An email was sent to participants with a link to complete the questionnaire. Reminders were sent to participants who did not complete the questionnaire. Participants completed the questionnaires during the peak of the first wave of the pandemic, between 30 June 2020 and 01 September 2020. We sent a total of five reminders. Most participants completed the questionnaire in July, with few responses received thereafter. There was therefore only one wave of responses. We did not perform non-response analysis as we did not have access to the demographic details of the participants who did not respond. Data were analysed descriptively and summarised in frequency tables. Comparisons between participant responses and whether they were working in an urban or rural area were made using cross-tabulations and the Chi-square or Fisher’s exact statistics. Content analysis24 was used to analyse the open-ended questions and the frequencies of themes identified. The process involved at least two of the authors reading the responses, dividing the text into meaning units and formulating codes. The codes were then grouped into categories and overarching themes. Once all the responses were coded and linked to a theme, the frequencies of the themes for each response were calculated. Verbatim quotes were added to support each theme. All the authors reviewed the themes and quotes for meaningfulness and credibility. Quotes were labelled as follows: female or male (F/M), age and rural or urban district (R/U). We obtained ethical approval from the Health Research Ethics Committee at Stellenbosch University (N20/04/015_COVID-19) on 15 March 2020. Institutional approval from Stellenbosch University was provided to access the email addresses of students and alumni after signing an agreement outlining the Protection of Personal Information Act 4 of 2013 requirements. Participants could read the online information leaflet and voluntarily decide to participate. Responses were anonymous and not linked to participants’ information.

AI Digest

Study Justification:

– Primary care nurses play a crucial role in responding to disasters and pandemics, including the COVID-19 pandemic.
– Understanding the reorganization of primary care services during COVID-19 is essential for effective management of patients.
– This study aimed to investigate the perspectives of primary care nurses in the Western Cape province of South Africa regarding the reorganization of primary care services during COVID-19.

Highlights:

– 83 participants, including professional nurses enrolled in a Postgraduate Diploma in Primary Care Nursing and alumni, completed an online survey.
– The majority of participants reported reorganizing services using various initiatives to address the diverse infrastructure, logistics, and services of healthcare facilities.
– Concerns were expressed regarding non-adherence of patients with chronic conditions, lack of promotive and preventative services, challenges with facility infrastructure, and staff time devoted to triage and screening.
– More than half of the participants indicated that other services were affected by COVID-19, and a significant proportion felt that these services were worse than before.

Recommendations:

– Ensure continued care for patients with chronic conditions and provide promotive and preventative services alongside COVID-19 management.
– Address challenges with facility infrastructure to support effective service delivery.
– Allocate sufficient staff time and resources for triage and screening.
– Mitigate the negative impact of COVID-19 on other essential services.

Key Role Players:

– Primary care nurses
– Stellenbosch University’s Postgraduate Diploma in Primary Care Nursing program
– Western Cape Department of Health
– Non-profit organizations and community health workers
– Nursing health services managers
– Academic experts involved in the COVID-19 response
– Experts working for non-governmental organizations involved in community education and testing

Cost Items for Planning Recommendations:

– Staff training and education on COVID-19 management and reorganization of services
– Facility infrastructure improvements and maintenance
– Equipment and supplies for triage and screening
– Additional staffing or reallocation of existing staff for increased workload
– Communication and information dissemination strategies
– Monitoring and evaluation systems to assess the impact of recommendations

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a quantitative study with a sample size of 83 participants. The study used an online survey with closed and open-ended questions to gather data. The findings suggest that primary care services in the Western Cape province of South Africa were reorganized during the COVID-19 pandemic, but there were concerns about the impact on patients with chronic conditions and the lack of preventive and promotive care. The study provides valuable insights from the perspectives of primary care nurses. To improve the strength of the evidence, future studies could consider a larger sample size and include a more diverse range of healthcare providers. Additionally, qualitative research methods could be employed to gain a deeper understanding of the experiences and challenges faced by primary care nurses during the reorganization of services.

Resumo

An exploratory-descriptive quantitative study was undertaken. The online survey was sent to Stellenbosch University’s Postgraduate Diploma in Primary Care Nursing students and alumni. This postgraduate diploma in Primary Care Nursing prepares nurses to assess, diagnose and manage a range of conditions in PHC settings. Admission criteria for a postgraduate diploma include at least two years of experience as a professional nurse. Students from various geographical locations in the Western Cape attend training at Stellenbosch University. The researchers had access to the contact details of these students and alumni, and they were therefore the accessible population for a rapid assessment at the time of the study which was conducted during the peak of the first wave of COVID-19 pandemic. The Western Cape province of South Africa is one of nine provinces and has a population of about 6.6 million people of which 64% reside in the City of Cape Town urban district. Three quarters (75.2%) of people in the province utilise PHC services.21 During 2019/2020, the Western Cape Department of Health reported 14.3 million PC encounters.21 The Western Cape has the highest life expectancy (68 years vs. 64 years on average for South Africa) and lowest maternal mortality rate (68.3 per 100 000 live births vs an average of 119 per 100 000 live births in South Africa) in the country.21 The three core services of the PHC platform in the Western Cape include: community-based care (via non-profit organisations and community health workers), PC (in 266 fixed and non-fixed facilities) and intermediate care. Primary care is driven by PC nurses and includes a range of services, including child and adult curative services, preventative services, women’s health, mental health, human immunodeficiency virus (HIV), tuberculosis (TB), and chronic disease management.21 The Postgraduate Diploma in Primary Care Nursing students and alumni that was the target population for this study also provide these services. Primary care nurses include professional nurses with undergraduate diplomas and degrees working in PHC settings as well as those who have completed an additional Postgraduate Diploma in Primary Care Nursing (Clinical Nurse Practitioners) that enables them to assess, diagnose, prescribe treatment for, and manage persons according to the PC guidelines.21 We developed a questionnaire based on the Impact of COVID-19 on the Nursing and Midwifery Workforce study (ICON) questions22 and other relevant literature. The questionnaire was based on the structures and processes needed for preparedness for COVID-19 and included: demographic information, COVID-19 training and attitudes, access to guidelines, facilities and equipment, services reorganisation, information, and training needs and personal or self-care needs. The questionnaire was reviewed by four external experts, including two nursing health services managers, one academic involved in the COVID-19 response in the Western Cape, and one expert working for a non-governmental organisation involved in community education and testing in relation to COVID-19. The experts suggested some changes to a few questions, as well as some additional questions, but were overall happy with the content of the questionnaire. The final questionnaire comprised of 48 questions, both closed- and open-ended. Open-ended questions allowed for participants to provide explanations or comments regarding their context that may have not been captured by closed-ended questions. For this article, we focused on the questions related to services reorganisation. Validity was ensured by developing the questionnaire from the literature and subjecting it to expert review. Reliability analysis could only be performed on the questions that measured similar concepts on a Likert-type scale. These questions related to confidence and preparedness (Cronbach alpha 0.7) and personal and self-care needs, specifically worry and anxiety (Cronbach alpha 0.75). Professional nurses enrolled for the Postgraduate Diploma in Primary Care Nursing (year 2020) and alumni from the years 2017–2019 were included (n = 251). We excluded nurses who were not working in PHC practice at the time of the study or who did not have working emails (n = 37). The total number of eligible participants was 214. We included the total population in the sample to account for non-responders. A minimum sample size 136 was needed for representativeness.23 A pilot survey was conducted to assess whether the questions were clear for participants and if they could easily follow the electronic link and complete the online questionnaire. We selected 20 students from the 2016 cohort of which 12 completed the questionnaire. We made a few adjustments to some questions and did not include the pilot data in the main study. An email was sent to participants with a link to complete the questionnaire. Reminders were sent to participants who did not complete the questionnaire. Participants completed the questionnaires during the peak of the first wave of the pandemic, between 30 June 2020 and 01 September 2020. We sent a total of five reminders. Most participants completed the questionnaire in July, with few responses received thereafter. There was therefore only one wave of responses. We did not perform non-response analysis as we did not have access to the demographic details of the participants who did not respond. Data were analysed descriptively and summarised in frequency tables. Comparisons between participant responses and whether they were working in an urban or rural area were made using cross-tabulations and the Chi-square or Fisher’s exact statistics. Content analysis24 was used to analyse the open-ended questions and the frequencies of themes identified. The process involved at least two of the authors reading the responses, dividing the text into meaning units and formulating codes. The codes were then grouped into categories and overarching themes. Once all the responses were coded and linked to a theme, the frequencies of the themes for each response were calculated. Verbatim quotes were added to support each theme. All the authors reviewed the themes and quotes for meaningfulness and credibility. Quotes were labelled as follows: female or male (F/M), age and rural or urban district (R/U). We obtained ethical approval from the Health Research Ethics Committee at Stellenbosch University (N20/04/015_COVID-19) on 15 March 2020. Institutional approval from Stellenbosch University was provided to access the email addresses of students and alumni after signing an agreement outlining the Protection of Personal Information Act 4 of 2013 requirements. Participants could read the online information leaflet and voluntarily decide to participate. Responses were anonymous and not linked to participants’ information.

Materiais

N/A

Inovações

Based on the provided description, it is difficult to identify specific innovations for improving access to maternal health. However, some potential recommendations could include:

1. Telemedicine: Implementing telemedicine services to provide remote consultations and support for pregnant women, allowing them to access healthcare professionals without the need for in-person visits.

2. Mobile clinics: Utilizing mobile clinics to reach remote or underserved areas, providing maternal health services directly to communities that may have limited access to healthcare facilities.

3. Community health workers: Expanding the role of community health workers to provide education, support, and basic maternal health services within their communities, bridging the gap between healthcare facilities and pregnant women.

4. Digital health tools: Developing and implementing digital health tools such as mobile applications or SMS-based platforms to provide information, reminders, and support for pregnant women, empowering them to take an active role in their own maternal health.

5. Collaborative care models: Establishing collaborative care models that involve multiple healthcare providers, including midwives, nurses, doctors, and specialists, to ensure comprehensive and coordinated care for pregnant women, particularly those with high-risk pregnancies.

6. Transportation support: Implementing transportation support programs to address the barriers faced by pregnant women in accessing healthcare facilities, such as providing transportation vouchers or arranging transportation services for prenatal visits and deliveries.

7. Maternal health education: Increasing access to maternal health education through community workshops, online resources, and partnerships with local organizations to empower women with knowledge and promote proactive maternal health practices.

These are just a few potential innovations that could be considered to improve access to maternal health. It is important to assess the specific needs and context of the target population to determine the most appropriate and effective strategies for implementation.

AI Innovations Description

Based on the provided description, the following recommendation can be developed into an innovation to improve access to maternal health:

Implement a telehealth platform specifically designed for maternal health services. This platform should allow pregnant women to access virtual consultations with primary care nurses and other healthcare providers, ensuring continuity of care during the COVID-19 pandemic and beyond. The platform should include features such as video consultations, secure messaging, and access to educational resources on prenatal care, breastfeeding, and postpartum care. Additionally, the platform should be accessible via mobile devices to reach women in both urban and rural areas of the Western Cape province. By leveraging technology, this innovation can overcome barriers to accessing maternal health services, such as transportation challenges and limited availability of healthcare facilities, while also addressing concerns related to the reorganization of primary care services during the pandemic.

AI Innovations Methodology

To improve access to maternal health, here are some potential recommendations:

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals for prenatal and postnatal care, allowing pregnant women to receive medical advice and support without the need for in-person visits.

2. Mobile clinics: Setting up mobile clinics in rural or underserved areas can bring maternal health services closer to communities, making it easier for pregnant women to access prenatal care, vaccinations, and other necessary services.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services, education, and support in their own communities can help bridge the gap between healthcare facilities and pregnant women, particularly in remote or marginalized areas.

4. Maternal health vouchers: Introducing voucher programs that provide financial assistance for maternal health services can help reduce the financial barriers that prevent some women from accessing necessary care.

5. Maternity waiting homes: Establishing maternity waiting homes near healthcare facilities can provide a safe and comfortable place for pregnant women to stay during the final weeks of pregnancy, ensuring they are close to medical care when they go into labor.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific group of pregnant women who would benefit from improved access to maternal health services, such as women in rural areas or low-income communities.

2. Collect baseline data: Gather information on the current state of maternal health access in the target population, including factors such as distance to healthcare facilities, availability of services, and utilization rates.

3. Model the interventions: Use mathematical modeling or simulation techniques to estimate the potential impact of each recommendation on improving access to maternal health. This could involve considering factors such as the number of additional pregnant women reached, the reduction in travel time or cost, and the increase in utilization rates.

4. Validate the model: Compare the model’s predictions with real-world data or expert opinions to ensure its accuracy and reliability.

5. Assess the outcomes: Evaluate the simulated outcomes of each recommendation, such as the increase in the number of prenatal visits, the reduction in maternal mortality rates, or the improvement in overall maternal health outcomes.

6. Sensitivity analysis: Conduct sensitivity analysis to explore the potential variations in outcomes based on different assumptions or scenarios, such as changes in population size, healthcare infrastructure, or funding availability.

7. Policy recommendations: Based on the simulation results, provide evidence-based recommendations to policymakers and stakeholders on the most effective interventions to improve access to maternal health in the target population.

By following this methodology, policymakers can make informed decisions on which innovations to prioritize and implement to have the greatest impact on improving access to maternal health.

Autor

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.4102/safp.v63i1.5358

ISSN: 20786190

Research Areas:

Community Interventions, COVID, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Mental Health, Quality of Care, Social Determinants, Workforce

Study Countries:

South Africa

Study Design:

Cohort Study, Cross Sectional Study, Exploratory Study, Phenomenological Study

Study Approach:

Quantitative

Participants Gender:

Male & Female

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