The time is now: missed opportunities to address patient needs in community clinics in Cape Town, South Africa

Abstract

Objective To investigate the prevalence and correlates of missed opportunities for addressing reproductive and mental health needs during patients’ visits to primary healthcare facilities. Methods We selected a random sample of participants from 14 of the 49 clinics in Cape Town’s public health sector using stratified, cluster random sampling (n = 2618). Participants were screened to identify those at risk for unsafe sexual behaviour and a mental disorder (specifically substance use, depression, anxiety, and suicide). Information pertaining to whether or not respondents were asked about these issues during clinic visits during the previous year was elicited. The rates and correlates of missed opportunities for providing reproductive and mental health interventions were calculated. Results The criteria of a strict definition of a missed opportunity for reproductive or mental health care information were fulfilled by 25% of the sample, while 46% met criteria for a looser definition. After adjusting for the effects of other variables in the model, men and Coloured respondents were more likely to have satisfied the definition of a missed opportunity for an intervention, while having completed high school and having children increased the likelihood of receiving an intervention. Conclusion Consultations with primary healthcare providers in which these issues are not discussed may represent missed opportunities. Persons presenting for routine care can be counselled, screened and, if required, treated. Interventions are needed at the patient, provider, and community levels to increase the opportunities to provide reproductive and mental health care to patients during routine visits. Le moment est maintenant: les occasions manquées pour répondre aux besoins des patients dans les cliniques communautaires à Cape Town, Afrique du Sud Objectif: Investiguer la prévalence et les corrélats des occasions manquées pour répondre aux besoins de la santé mentale et de reproduction lors des visites des patients dans les services de santé primaire. Méthodes: Nous avons sélectionné un échantillon aléatoire de participants dans 14 des 49 cliniques du secteur publique de santé de Cape Town en utilisant l’échantillonnage stratifié, aléatoire en grappes (n = 2618). Les participants ont étéévalués pour déterminer ceux à risque de comportements sexuels à risque et de troubles mentaux (en particulier l’usage de substances, la dépression, l’anxiété et le suicide). Des informations relatives à l’opportunité ou non pour les répondants d’avoir été interrogés sur ces questions lors des visites à la clinique au cours de l’année précédente ont étéélucidées. Les taux et corrélats des occasions manquées de fournir des interventions de santé reproductive et mentale ont été calculés. Résultats: Les critères pour une définition stricte d’une occasion manquée pour des informations sur les soins de santé mentale ou de reproduction étaient remplis par 25% de l’échantillon, tandis que 46% répondaient aux critères d’une définition plus souple. Après ajustement pour les effets d’autres variables du modèle, les hommes et les répondants de couleur étaient plus susceptibles de satisfaire à la définition d’une occasion manquée pour une intervention, alors que le fait d’avoir terminé les études secondaires et avoir des enfants augmentaient la probabilité de recevoir une intervention. Conclusion: Des consultations avec les prestataires des soins de santé primaire au cours desquelles ces questions ne sont pas abordées peuvent représenter des occasions manquées. Les personnes se présentant pour des soins de routine peuvent être conseillées, évaluées et, si nécessaire, traitées. Des interventions sont nécessaires à l’échelle du patient, du prestataire et de la communauté pour augmenter les possibilités de fournir des soins de santé mentale et reproductive aux patients lors des visites de routine. El momento es ahora: oportunidades perdidas para ocuparse de las necesidades del paciente en clínicas comunitarias de Ciudad del Cabo, Sudáfrica Objetivo: Investigar la prevalencia y la correlación entre las oportunidades perdidas para ocuparse de las necesidades en salud reproductiva y mental de los pacientes que se visitan en centros de atención primaria Métodos: Hemos seleccionado una muestra aleatoria de participantes de 14 de las 49 clínicas del sector sanitario público de Ciudad del Cabo, utilizando un muestreo estratificado, aleatorio y en conglomerados (n = 2,618). Los participantes fueron tamizados para identificar aquellos en riesgo por comportamientos sexuales de riesgo y desórdenes mentales (específicamente uso de sustancias, depresión, ansiedad y suicidio). Se obtuvo información sobre si a los participantes se les habían preguntado acerca de estos temas durante el año anterior. Se calcularon las tasas y correlaciones de las oportunidades perdidas para proveer intervenciones de salud reproductiva y mental. Resultados: Los criterios de una definición estricta de oportunidad perdida para informar sobre cuidados reproductivos o mentales fueron alcanzados por un 25% de la muestra, mientras que un 46% cumplía criterios para una definición más laxa. Tras ajustar para los efectos de otras variables en el modelo, los hombres y participantes de color tenían una mayor probabilidad de haber satisfecho la definición de una oportunidad perdida para una intervención, mientras que el haber completado el bachillerato y tener niños aumentaba la probabilidad de recibir una intervención. Conclusión: Las consultas con proveedores del sector sanitario primario, en los que no se discuten los temas en cuestión, pueden representar oportunidades perdidas. Las personas que acuden a cuidados rutinarios pueden ser aconsejadas, tamizadas, y en caso de requerirlo, tratadas. Se requieren intervenciones a nivel del paciente, del proveedor y de la comunidad para aumentar las oportunidades de proveer cuidados reproductivos y mentales a los pacientes durantes las visitas de rutina. As in many parts of the world, the public health care system in South Africa is based on the principles of universal primary care. This implies a comprehensive service, which includes the integration of services such as reproductive and mental health care into the primary health care system. Integration aims to improve services in relation to efficiency and quality thereby maximizing use of resources and opportunities (Briggs & Garner 2006). However, according to the global report by the World Health Organization (WHO 2003), there is substantial evidence to suggest that many countries are struggling to implement this programme and are not experiencing the expected results. Although in South Africa primary care is responsible for providing basic health services to all, many may have needs for services apart from those requested. With only a quarter of South Africans suffering with a psychiatric disorder receiving treatment (Seedat et al. 2008) and 10.9% of all South Africans over 2 years old living with HIV in 2008 (HSRC 2008), it is not unreasonable to suggest that many would benefit from sexual health and mental health interventions during their primary healthcare visit. If these needs are not identified by the primary healthcare provider, this constitutes a missed opportunity to provide services. On the other hand, if needs for additional services are identified and addressed on the same clinic visit, higher coverage and more cost-effective service delivery can be achieved. A number of studies conducted in the developed world have investigated missed opportunities in various aspects of healthcare including: immunizations (Yach et al. 1991; Nowalk et al. 2004; Turner et al. 2009), cancer screening (Reinhold et al. 2005), early detection of HIV (Kuo et al. 2005; Burns et al. 2008), STD and pregnancy counselling (Tao et al. 2000), and substance abuse and suicidal behaviour (Frankenfield et al. 2000; Weisner & Matzger 2003; Chang et al. 2008). The findings of all of these studies conclude that primary healthcare providers are failing to use clinic visits as an opportunity to provide effective preventive and diagnostic services. The studies that have investigated missed opportunities in South Africa have predominately focussed around the issue of immunization (Yach et al. 1991) and reproductive health needs in various populations such as HIV-infected women in antiretroviral therapy programmes (Myer et al. 2007), mother to child HIV transmission (Rispel et al. 2009), and contraception counselling for youths (Flisher et al. 1992). Most of the studies conducted both in South Africa and in more developed countries consider a missed opportunity as simply not having received services. However, Flisher et al. (1992) used specific criteria to define missed opportunities for contraception counselling in their study of 225 youths attending community health centres. Results indicated that 8% of the total sample met criteria of a strict definition of missed opportunity for contraception counselling. Additionally, 44% of sexually active adolescents and 44% of non-sexually active adolescents did not receive an intervention, despite indicating that they would have liked one. The only variable that correlated with whether a missed opportunity occurred was having had more than one partner in the previous year. Very little is known about the extent to which primary healthcare providers address the reproductive and mental health care needs of their patients. Therefore, the purpose of this study is to document the prevalence and correlates of missed opportunities for these health issues in a large, representative sample of patients using the primary care service of the public health system in Cape Town, South Africa. The study employed a multi-stage stratified, clustered sampling design in which we first stratified and sampled clinics, and then patients within clinics. Consistent with other South African research, we stratified the 49 clinics providing primary care in Cape Town by race as defined under apartheid, because of the continuing association with health disparities and socio-economic status (McIntyre et al. 2002; Mager 2004). The population served by the public health sector is chiefly Black and Coloured (mainly of mixed African, Asian or European ancestry), and so we stratified clinics into those serving populations 80% or more Coloured; 80% or more Black; and a more diverse population (i.e. serving approximately equal numbers of both). The ‘Black’ and ‘diverse’ strata were approximately equal in size, and the ‘Coloured’ stratum was 1.5 times the size of these. We randomly selected 14 clinics (proportional to the annual number of visits): six from the larger Coloured stratum and four from each of the proportionately smaller others. We recruited for 4 weeks at each clinic, sampling equally all days of clinic operations across clinics. The study was approved by the institutional review boards of the University of Cape Town, the University of California, San Francisco and Kaiser Permanente’s Department of Research. On data collection days, we constructed a log of all patients who registered, along with their age, race, and gender. From this log, we randomly selected patients, except that we sampled every patient aged 18–24 as this age group attends clinics less frequently and is particularly at risk for substance use (Ward et al. 2008). The patient log data were also used to construct weights to estimate population-level statistics. The recruitment rate was 43%; non-response was due primarily to attempts to recruit patients who, when sought by the interviewers, were not available. Of those patients who were not interviewed, 14.9% (525 patients) were not interviewed because the available fieldworkers did not speak their language, they were too ill to be interviewed, or fieldworkers judged them too cognitively impaired to give informed consent. Only 142 (4.0%) refused the interview. In the majority of cases where patients were not interviewed (2866 patients, or 81.5%), these patients left the clinic in the time between having been seen by the physician and a fieldworker’s being available to conduct the interview. Depending on physician staffing patterns, some clinics had shorter waiting periods; some also had fewer interview rooms, so that fieldworkers could not always enrol patients in the study before they left the clinic. Because the recruitment rates were primarily related to practical arrangements within the clinics, it is unlikely that there is systematic bias in terms of the variables of interest (or of sample characteristics such as race or gender; for details on recruitment, see Ward et al. 2008.) Our weights adjust for differences between the sample and population in the clinics represented. Interviewers recruited patients as they waited for their medical visits. Patients were interviewed in they had their medical by a who was for and The information was during the risk for sexual substance and whether they had received information these health issues at the and whether they would have to have received such The was developed in into and and into After the respondents were a of and those who had behaviour were to data age years of age, and race Coloured of numbers of and they were from the high school not completed high and number of Additionally, the number of visits to the primary healthcare in the previous year was from The rates of missed opportunities for reproductive and mental health interventions were according to of criteria as in be that the criteria are and give a higher estimate of the rate and are to the in of the on missed opportunities for Turner et al. et al. 2005; and et al. In this a missed opportunity occurred when a is to have risk in a health was not asked about that during the health visit. the criteria 2 are based on Flisher et al. (1992) and are strict and would give a estimate of the rate of to if a missed opportunity criteria for definition be and in the whether information about this health sexual behaviour was by whether or not the had had sexual to use to pregnancy or and met criteria for one or more of the of sexual in the year for or did not HIV of sexual in the year had been men who had had with other of sexual in the year had had an time had they had not known their partner than that their sexual over the year had been in terms of We used the and to prevalence of substance were for each substance where use was in the can be as and use for use, which can only be high or risk use, high risk high of et al. We the risk at the of risk so that and high were and and no risk were To for and depression, we asked questions for each from the Health et al. If respondents to both questions for or they were at risk was by questions on and whether or not the respondents received medical care for If respondents to one of the they were at Additionally, whether or not the had been asked about or information about their reproductive or mental health to as an was elicited. the was asked about and anxiety, of visits in the did a or about such as or to whether or not the received an intervention. The also asked whether or not they about these were using were to adjust for the of to non-response rates age, and within clinics and the size of clinics to the population served by Cape Town’s Health from to = = We the between missed opportunities to definition looser as the and characteristics as was based on and at = In were developed to for and variables age, race, number of and The first was based on whether missed opportunity while the four investigated missed opportunities for sexual substance use, and interventions The of the were as with A total of of were men and were were recruited as they waited for their medical visit. The sample of a majority of Black respondents by Coloured with or Only were years were and had less than a high school were and had The criteria for the strict definition of a missed opportunity for were fulfilled by 25% of the total sample and by 46% for the looser definition The missed according to the looser was for by sexual and reproductive health substance use and whether or not the to be asked about health in the strict sexual health was the frequently missed by substance use and of the sample were asked about their substance use, about their sexual and reproductive 8% about and about This is despite of the respondents being at risk for and only of respondents being at risk for substance The and effects of characteristics on missed opportunities are in and After adjusting for the effects of other variables in the model, men were more likely to have satisfied the definition of a missed opportunity for an than women = men were more likely to criteria for a missed opportunity for a reproductive health and substance use = However, being increased the likelihood of receiving a and = Coloured respondents were more likely to the criteria for a missed opportunity than Black respondents = However, this to have been because of the higher rate of missed opportunities for and interventions Coloured respondents = respondents were more likely to have satisfied the definition of a missed opportunity for a = completed high school increased the likelihood of receiving an = However, at the specific health this was only the for = and and not for substance use or reproductive health interventions = respondents were more likely to have satisfied the definition of a missed opportunity for a reproductive health = substance use, and = interventions than children increased the likelihood of receiving an = for reproductive substance use = and interventions than respondents with no The number of clinic visits in the year increased the likelihood of receiving an = for reproductive health = and substance use, increased the likelihood of criteria for a missed opportunity for a = This study had a number of The criteria for a strict definition of a missed opportunity for reproductive or mental health care information were fulfilled by 25% of the sample, while 46% met criteria for the looser definition. issues related to substance use and to a extent reproductive health are depression, anxiety, and to be A number of variables the of a missed opportunity in primary and these by the of this study that many South Africans who may benefit from reproductive and mental health interventions are not receiving these services in primary care. A of been to the of primary health care the health and in of public and & Although these issues are also to the of this these findings also to at the patient and at the specific healthcare health care providers are frequently interventions on substance Only 8% of participants met criteria for a missed opportunity for substance use, with of all respondents having received a substance use intervention, despite only being at risk for substance use and to receive an intervention. data from a representative sample high prevalence and early of substance use et al. 2008). However, because of the of this the more in use is not in Because South Africa a increase in use which occurred a of increased use, other such as and & this may not be such a was the that many South Africans met the criteria of a missed opportunity for a and interventions Although there are no data missed opportunities for psychiatric in South in the only of interviewed screening their patients for risk (Frankenfield et al. to more developed in South the risk for suicidal behaviour is the of a psychiatric to for a representative in South of who at some in their having a The with the association with attempts were by disorder and et al. in one study in a Cape Town primary care that of the patients to and of these patients, and et al. A number of to screening for psychiatric are in the for this may high and a of service of the of mental on patient in South interviewed in primary care to their of mental health health Results indicated that to psychiatric such as and have that these providers have to service which they as an to their primary healthcare providers in mental health can be by or patient to conduct mental health Patients who may then be by or and to mental health services if is that be developed to address and that these are at the the that been on sexual and reproductive health in South Africa over the it is not that the rate of missed opportunities was only of which definition was Although the of missed opportunities for reproductive health interventions is also in previous studies service delivery (Myer et al. 2007), the of this of women receiving care in South a majority that their were et al. 2006). to address all missed opportunities in the of sexual and reproductive South Africans primary healthcare be reproductive and sexual health care counselling. The of this study that a number of variables the of a missed opportunity in primary and these by With the in when at the specific it that health care by of or by their may of reproductive and mental health care issues to patients they to be at to specific may a numbers of patients that could benefit from and counselling. of this study be when these data are based on and are to the of the of the study not to address a number of patients were However, this was likely by related to the to patients and not to the variables under and so is unlikely to have systematic bias (Ward et al. 2008). the quality of interventions was not investigated in this we are to whether the interventions were in However, despite these it is that there is a high prevalence of missed opportunities in primary care clinics in the public health in South particularly and that the of primary care is as as the and This includes the of of primary such as of comprehensive and to cost-effective and quality care. could be to the of screening in primary care consultations being addressed in this the extent to which these principles are being as of the for such may be an of Flisher a with during the of this We to particularly in the of this of and of this is to we are are and for their the Health Organization and the Health of the of Cape Town, for to conduct this in their and and of the of South who the and the we clinic for all their and the patients who their time to in the This study was by from the of of under African Research.