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Category 1: Existing guidelines, services and current practices in the clinicsCurrent GDM screening/care guidelines and its poor implementation “So, what we basically do in our facility, so we go according to the BANC protocol. We have our own protocol. If a mother comes in the morning for an antenatal booking, then we test her urine…”. HCP 1. From no testing to the risk-based screening of GDM at the clinics Risk factors assessment “There are two Community Centres in Gugulethu, the, and then it’s us, the mobile Baby Clinic. In our clinic it’s basic antenatal care, so the people who have a history with parents who are diabetic, usually we send them to the MOU, they are screened that side. We don’t do screening in our clinic. We don’t actually do that”. HCP 3. “Not every mum, but if she presents risk factors such as a family history of diabetes, the mum had a previous history with Gestational Diabetes, she has an exceeding Body Mass Index (BMI) and then if we tested the random blood sugar and found that it was above 7.8, then we will give the mother a Gestational Diabetes check…”. HCP 4. “So we do a random blood glucose at the facility, and depending on that result, we will then follow the necessary steps. There is obviously a screening in terms of family history, and have you had Diabetes before, or do you currently have Diabetes….”. KI 6. Process of GDM testing and referring women with GDM “the procedure for screening, we’ve got a list of indications for doing Glucose Tolerance Test (GTT): family history of diabetes from her mother, her father or her siblings, BMI of 35 and above, history of big babies, persistent Glycosuria; for three consecutive visits. She has to come in the morning, fasting, her last meal the previous night around 10 o’clock. So, when she comes, we do the prick. If the sugar is 7 and above, we don’t continue, but if it is less than 7, we take the fasting blood and we give her 75 grams of glucose, and we take the second blood after two hours. So, they come after one week for the results. If it’s an IGT, we refer to Mowbray not Groote Schuur, but if it’s GDM, then we refer to Groote Schuur”. HCP 2. “when they come here for the first time, we do the IGT (Impaired Glucose Tolerance) test or sugar test, and then if there is family history like the mother was diabetic, then we do the OGTT test, which is the fasting glucose, but we don’t do it here. I have to book for them in Gugulethu, and then they are going to give me the date when the patient can go there. Otherwise we have the forms that we use. We just take… I’m going to show you later the forms, and then we take, if the patient has already diabetes and she does not qualify to book here at the clinic, so I refer the patient straight to Gugulethu MOU”. HCP 5.
Barriers to GDM screening into PHC “Well, the current practice is to try and identify them from women who attend antenatal care. That obviously means, the people who don’t attend, we wouldn’t pick it up…” KI 2. “You know, unfortunately a lot of the patients are picked up a bit later. The patients we pick up earlier of course, are those who previously diabetes, which is a different ballgame. So those get to come in early, but the majority of the patients come in at a later time…”. KI 3. “The only challenge is that when you give an appointment for the lady to come to do bloods, then she doesn’t come. Then it will be picked up because they are supposed to do it before they are 28 weeks; or if you do it at 28weeks then you have to repeat it. If it was borderline then you have to repeat, so then you don’t have that chance of checking if you pricked them already at seven months or close to eight months, so you don’t have that chance of checking, then you are going to refer them, because they are already late in pregnancy”. HCP 6. “….The presentations are varied, and 50% of patients that are currently diabetic don’t know yet that they have Diabetes. So I think anyone allied to the healthcare should be thinking about screening and actually being able to screen….”. KI 1. “I don’t think it’s okay, because sometimes we miss them, because maybe, it depends, maybe the family doesn’t have diabetes and the person can develop Diabetes during pregnancy. So sometimes, if it’s not picked up in the urine, and we don’t often do the diabetes test every time, it’s not like Hypertension, it’s not… I don’t think we are doing a good job in this case. There are no signs you know, if it’s high….”. HCP 2. “We don’t have time to talk individually, but at times when we give the Health Talk, we do explain to them…”. HCP 4. “You call an ambulance to pick up the clients to take to the MOU, or Mowbray, depending on where the pathway is. Now we send the letter. On the letter there is a sleeve that is supposed to come back to us, but that has never happened. I have been here for more than eight years now, I have never seen that sleeve coming back…”. HCP 7. “She must bring her own food, because we do not have glucose to eat. She goes and has breakfast, and then two hours later we re-prick…”. HCP 1.
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Category 2: Effective antenatal referral procedures but lack of follow-up after deliveryOn-site integrated hospital services “she gets referred to Groote Schuur Hospital’s antenatal clinic where they will do what we call OPD (Out-Patients Department) spreads, and then they will start treatment; but the first line treatment for any diabetic is diet, and so she will see the dietician, lifestyle changes, and then she will start treatment…”. HCP 8. “nurses play an indispensable role in managing these patients, bearing in mind that the maternal and foetal wellbeing will be first assessed by nurses, and also nurse will also help in providing anthropometric measurements, they help to also reduce the time-lapse in some of these patients to spend a very long time waiting for doctors. So basically, nurses play a role in monitoring of the mother and the baby, as well as even sometimes in diagnosis and also in management”. KI 5. We all have our specialities, so the registrar that would be looking after the patient is somebody that is rotated through the whole block, so they’ve seen cardiac, they’ve seen eclamptic patients, they’ve done diabetes; but if there is a specific problem, then we are in the fortunate position where we have the resources where we can get infectious disease people out, instead of struggling with that, or we can get the endocrinologist out, and say listen, we have now hit a wall, how do we go forward, but that is within our setting”. HCP 8. Socio-economic boundaries to healthy antenatal and postnatal initiatives “…. sometimes when you check in, they say you must come without eating to the clinic and then they take a long time to check your sugars, and then you get tired, you are hungry. You know how you are when you’re hungry, you seriously want to”. Participant in FGD 1. “…. Like delays, and it’s now the strike, so there are no busses, so the trains are full; taxis you have to wait in line, and you know when you are pregnant, to stand for a long time in line, it also causes back pains; like now, I’ve got a huge back pain from standing in the line”. Participant in FGD 4. “…. Sometimes you just want to ask a small question and the sister goes to levels like (she gets upset and shout). She doesn’t even know the question that you want”. Participant in FGD 1. “…You come from work, even if you get your day off, you are tired, thinking about exercising, even if you want to, but your body doesn’t allow you to do so, because you are tired”. Participant in FGD 3. “…For me it’s very tough, to change my diet, because I’m used to eating. For me it’s really… and it’s not easy; that is why I’m cheating sometimes. Participant in FGD 2. Confusion or little knowledge of women on GDM and lifestyle changes “…this is my second child, I didn’t have sugar. Nobody in my family has sugar. I find out my sugar is high in my blood, so the doctor explained to me I must go on the Insulin, because otherwise I can have a miscarriage; and I don’t understand actually, maybe can it be, or what….”. Participant in FGD 2. Poor communication and inexistent plans for postnatal follow-up We don’t have a six week visit. We don’t have a six week visit. When six weeks postnatally, the baby is six weeks, so at six weeks they go to the Baby Clinic, so they don’t come back to us, that’s the thing. HCP 9. “There is no strict channel. Obviously, there is very detailed discharge information about what the diagnosis is, what the implications are, and what needs to be done in the interim. But as to whether people phone and follow up…? You know, there isn’t that, and there needs to be; not only in the management of GDM, but in the management of a lot of patients that we see for whatever medical reason…”. KI 3. “So, I think firstly the doctors and nurses don’t always have enough time, and also, they’re not very knowledgeable, and then even the dieticians are sometimes giving the wrong messages because of this whole debate internationally. So, I think those things are a problem, and then there is also the issue of healthy foods being expensive in townships, and the issue of exercise is difficult. I mean, if women get up at five o’clock, go to work in the town, go back, don’t get home till seven, you know, their lifestyles aren’t conducive to exercise”. KI 4. “The maternity sisters do not communicate with the local clinic sister for follow-up on these clients about medication after delivery and then we don’t know. So, maybe they got letters from hospital that you must follow up at this clinic to get your medication that is going to control you but mothers don’t follow up, as I have noted, they don’t follow up, they only focus on the baby after delivery, they focus on the baby. They don’t go for that follow up appointment and the medication, especially after they are coming from Maternity. But if there is a problem, then the doctor prescribes when discharging them but they will never mention it to us at the clinic…And then, if they are with the person who didn’t see them when pregnant, you won’t know if the client had a problem with the glucose”. HCP 10. “I mentioned earlier about the six weeks postnatal visit that needs to take place, and our nurses are overworked and understaffed, and I can attest to that. On any given day it is hectic in front, and staff shortages and absenteeism and people not adequately trained. People get pulled from one department to another to go and help out, and so all in all, what I’m trying to say is the six weeks postnatal visit, I don’t think to my knowledge that it is actually happening, that is, not in our facility”. KI 6.
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Category 3: IINDIAGO, an intervention with potential to bridge the gaps“It is now policy. We had it two or three years ago, we wrote a postnatal care policy for the Western Cape, and I was involved in writing it, and it’s agreed, it’s just no-one has implemented it. So, it has to be implemented.… So, I do think it needs to be resourced. You need another nurse, and you need a particular training to give that nurse the referral route. So, what does she do with a person who’s depressed at six weeks? What does she do with the one who had GDM and they’ve checked her sugar now and it’s normal? What do they do with her? So, I think it needs almost a little bit of a syllabus for what the nurse does, you know?”. KI 4. We see it with IGT patients who are very well counselled and can actually reverse the whole and become normal. So, I think it’s feasible. I think it’s good that it (IINDIAGO) will give you raw data that you can then present to policymakers and say, listen, although we knew this, this is the hard data, done in a methodologically robust manner, and that no-one can argue with. And once faced with that, then one will have to change policies, and be forced to change the infrastructure and the way the infrastructure is set up to deal, not only with Type 2 Diabetes but with many other problems. KI 3. “I think if we can implement it (IINDIAGO) at the Well Baby Clinics for instance if they have enough staff and they are well-trained, I think it would make a big difference, because as a mother sometimes you are more worried about your baby, so then you are more likely to access that service; and then I think, like I said earlier, a continuation of care is better… So, if she has that continuous support at the Well Baby Clinic, because that is a place where she will be accessing the services quit e frequently, so she will be able to build a bond or a type of relationship with that caregiver on that side as well”. HCP 8. “It (IINDIAGO) is a good thing, because we such type of intervention we will normally check if everything is good when they come for post-delivery. We now just focus on breastfeeding and not in that side. We don’t go on the Diabetes side and Hypertension and all those things”. HCP 6.
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Category 4: Encouraged role of CHWs involvement toward community based T2DM prevention intervention“You see, I think because the women with GDM after pregnancy, most of them don’t have any medical problem, the doctor or nurse will think they are wasting their time at the clinic, so, actually the initiative should be a community based one through lifestyle, and I think the community health workers are most important…but I don’t know the answers about the scope of a community health worker”. KI 4. “We also have health care workers that are not based in the clinic, but they report. Those are the people that are helping us work or supervising the ART or TB treatment for the people that are placed in the community to take their treatment. They visit. Even with the immunisation that is really not doing so well, they are able to the visits, the home visits. They are in contact with the community, so they also can help in this intervention (IINDIAGO)”. HCP 10. “…they also help us with recalling the mothers for other things. I think they can also play a role in this intervention (IINDIAGO)”. HCP 11. “For me, I think that the community workers are people from the community, so, the patients trust them more than coming to a sister in a hospital they can only see once.… so, the community knows them. If they do the screens and stuff they tend to trust them more than us some times. Yes, I think they need to be trained, because the last time I said they even need to be trained in doing prognostics for us, then they can do the diabetic screening at the same time, different screenings; because they are there in the house with ten people around them, so they can do all of that, and then they catch them early, even the blood finger prick”. HCP 4. “We have this form called household chart, here is a copy. So, inside house with the members of the household, and then you ask all these questions. Maybe there is someone who has symptoms of TB, who is HIV Positive, who is interested to test, then you advise to go and test. I give some card that we write in for follow-up on that date, referral cards. You tell them go to Crossroads if you are feeling that you are hypertensive and get your medication there. Diabetics, they talk a lot like I am drinking a lot of water. I am always tired, they talk about all those symptoms to you when you get there, so you record them and you check all the symptoms…You advise them about immunisation, Vitamin A, etc”. Participant in 1, FGD 1. “And even if it’s difficult, and they don’t want to come to the clinic, you as a CHW, you help her to start medication again. You educate people about their health, you tell them what is going to happen to them if they keep doing this or that? For example, you say to the patient that if you don’t go there and take your medicine, this is going to happen to you”. Participant 1, FGD 2. “Me, I love the job that I am doing because I don’t have a problem with people, and I can convince them but if someone is not doing well, I report her to the supervisor who will then intervene”. Participant 3, FGD 1. “My challenge is work load. We have to record. We have to be ready to give weekly and monthly statistics for our work. It’s a challenge, because there is a lot of work. We have to visit the clients, rain or shine, you have to visit them. You must have the minimum six to eight, and then each and every day you must have something to write down as proof of what you have done for the day. We must also cover many households at a long distance and reach target…. Participant 5, FGD 1. “Sometimes when we arrive at a patient, we see a number of men smoking. The whole house is like snow, so I am afraid of entering that house fearing what could happen to me when I enter that house”. Participant 3, FGD 2. “Challenges also include robberies in the community and even here at the clinic, they just come and attack you at the clinic’s gate and sometimes we are not working with our cell phones because we are afraid of robbery by the gangsters. And sometimes, even in the houses that they are going to do the pill counts in, they mustn’t go alone. We must therefore be two or three but it is not easy to get that one to make a friend and go together to avoid those incidents”. Participant 4, FGD 2.
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