Presentation Abstracts
In session order

Procedures performed by family physicians in hospital practice in a developing country
J.M. BOON ¹, P.H. ABRAHAMS ²., J.H. MEIRING¹, T WELCH³,
¹ Department of Anatomy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
jboon@medic.up.ac.za

The safe and successful performance of office procedures, surgical procedures, and emergency procedures as well as radiological imaging procedures demand a working and yet specific knowledge of anatomy. This study focuses on the competency to perform clinical procedures, especially the underlying anatomical knowledge base necessary to perform a safe and successful procedure. No study reports on the assessment of clinical anatomy as part of the competency of family physicians to perform clinical procedures.
The aim of this study was to determine a) which clinical procedures are performed in hospital practices in South Africa; b) the frequency of performance; c) the importance rating of clinical procedures; d) the comfort of performance; e) difficulties and anatomically related complications encountered; f) the role of clinical anatomy competency in reducing difficulties and complications; g) the role of clinical anatomy in improving confidence of performance; h) a selection of 15 problem procedures; i) the relevant clinical anatomy necessary to perform these procedures and j) to develop a clinical anatomy training program for these procedures.
A list of 57 procedures relevant to family practice in South Africa was compiled and a questionnaire completed by doctors at various hospitals, which were randomly selected in three provinces in South Africa. A total of 102 questionnaires were obtained and analyzed.
The following procedures were selected: Central venous catheterization, cricothyroidotomy, pericardiocentesis, great saphenous vein cutdown, oro/naso tracheal intubation, lumbar puncture, appendectomy, cesarean section, reduction of uncomplicated forearm fractures, ectopic pregnancy surgery, epistaxis and nasal packing, rectal examination, proctoscopy and sigmoidoscopy, knee joint aspiration, wrist and digital nerve block and obstetric ultrasound. A referenced knowledge base was developed by an extensive literature search of the selected procedures under the following headings: Indications, contraindications/ precautions, step by step procedure, anatomical pitfalls and anatomically relevant complications. This was expanded to develop a Virtual Procedures Clinic, an interactive multimedia package which will be demonstrated.

A multidimensional approach to chronic pain
HP Meyer, Department of Family Medicine, University of Pretoria
dbosch@kalafong.up.ac.za

Chronic pain affects hundreds of millions of people worldwide and often has a profound influence on the patient's mood, personality, physical functioning and social relationships. Chronic pain is often mistreated or under-treated and the rise in the use of non-traditional health-care providers partly reflects the large number of patients with chronic pain, especially chronic headache, neck- and back disorders who go outside of mainstream medicine to seek help.
Chronic pain may be caused by persistent stimulation of pain receptors (nociceptors) due to ongoing tissue damage (e.g. osteoarthritis). However, chronic pain frequently persists long after the tissue damage that initially triggered the onset, e.g. whiplash injury, has resolved, due to neuroplasticity and "centralization" of pain. It may also present in patients without ongoing tissue damage or previous trauma, often with a genetic tendency.
This workshop will focus mainly on these common chronic pain syndromes where there are no confirmatory laboratory studies and diagnosis is based on clinical criteria alone e.g. fibromyalgia and myofascial pain syndromes.
Fibromyalgia is an increasingly recognized and common disorder of chronic widespread musculoskeletal pain and these patients have a high prevalence of headaches, esophageal dysmotility, irritable bowel syndrome, insomnia, chronic fatigue, depressive disorder etc.
Myofascial pain syndrome (MPS) is a regional pain disorder and a very common cause of backpain and chronic headaches in the primary care setting. MPS is characterized by trigger points in muscle with referred pain on manual compression.
The family practitioner should use a biopsychosocial approach in the assessment and intervention of chronic pain. In the workshop, different modalities of physical therapy, exercise, myofascial trigger-point infiltration techniques, principles of drug therapy and behavioural/cognitive aspects will be addressed. Emotional conflict, anger and anxiety may precipitate or exacerbate pain and potential relationships between pain and interpersonal dynamics should be evaluated.

The professional skills of medical practitioners serving the rural communities of the western cape - implications for service and training
M de Villiers, Head: School of Public and Primary Health Sciences, Faculty of Health Sciences, Stellenbosch University
MRDV@sun.ac.za

Introduction: The majority of the world's poor live in rural areas, enduring poorly coordinated or non-existent health services, with their health status further compromised by a global shortage of health professionals in rural areas. To improve the health of our rural people it is imperative that policies and training for sustainable rural practice be developed and implemented, based on an understanding of what is happening in rural hospitals. The aim of this study was to establish a profile of district hospitals in the Western Cape and investigate the professional skills of medical practitioners staffing these hospitals.
Methodology: Information was collected from the 27 district hospitals in the Western Cape (casualty register, theatre register, standard statistic sheets, questionnaire) and all 147 medical practitioners (questionnaire and in-depth interviews).
Results: The 27 hospitals had a total of 1528 beds, with a monthly mean of 772 casualty patients, 1690 outpatients, and 70 operations per hospital. Musculo-skeletal complaints were the most frequent reason for presenting at casualty departments. Caesarean sections were the most commonly performed surgical procedures, with general anaesthesia the main method of anaesthesia. Skills level assessments performed in 5 categories (in-patient, emergency and trauma, out-patient, outreach and support to primary health care, and management) are reported. Original conceptual frameworks were developed from the qualitative interviews namely the "Inverse skills quality circle " and the "Skills Boat" depicting the factors influencing the professional skills of practitioners working in rural hospitals.
Discussion: The district hospitals in the Western Cape are rendering a huge and extremely important service to our rural communities but are hampered in their functioning by a number of factors. Training institutions need to take into account the prevalence of certain procedures and skills essential for rural practice in the training of medical practitioners for rural areas. The report makes recommendations on how the skills gap may be addressed to improve the health services to rural people in the Western Cape.

Skills audit work group workshop
Janet Giddy and Bernhard Gaede
jgiddy@eject.co.za

This workshop will look at finalising a skills audit for rural / district hospital doctors. It is a useful tool in assesing competency and planning training needs. A group of generalist doctors have been working on the list of skills via email and will meet to discuss outstanding issues. The workshop is for anyone who is interested and not only those who have been part of the working group so far.

Why babies die: A perinatal care survey of South Africa 2001
Bob Pattinson, Kalafong Hospital, MRC Maternal and Infant Health Care Strategies Research Unit, Department of Obstetrics and Gynaecology, University of Pretoria
rcpattin@kalafong.up.ac.za

Aim: To identify the major causes of perinatal mortality and the avoidable factors, missed opportunities and substandard care regarding perinatal care, in South Africa.
Setting: Forty-four state hospitals throughout South Africa representing metropolitan areas, cities and towns and rural areas.
Method: Users of the Perinatal Problem Identification Programme (PPIP) amalgamated their data to provide descriptive information on the causes of perinatal death and the avoidable factors, missed opportunities and substandard care in South Africa.
Results: A total of 3045 perinatal deaths of 1000g or more were reported from 78 343 births at the PPIP Users sites. The perinatal mortality rates for the metropolitan, city and town and rural groupings were 38.4, 43.4 and 25.5/1000 births, respectively. The neonatal death rate was highest in the city and town groups (16.5/1000 live births) followed by the rural and metropolitan groups (11.1 and 10.7/1000 live births respectively). The low birth weight rate was highest in the metropolitan group (21.4%), followed by the city and town group (18.6%) and the rural group (13.7%).
Unexplained intrauterine deaths were a common grouping of primary cause of death in all groups. The most common primary cause of perinatal death in the Rural group was intrapartum asphyxia and birth trauma (rate 6.28/1000 births) followed by spontaneous preterm delivery (6.07/1000 births). The most common primary cause of death in the City and Town group was spontaneous preterm delivery (7.48/1000 births) followed by antepartum haemorrhage (7.0/1000 births) and intrapartum asphyxia and birth trauma (6.8/1000 births). The Metropolitan group's most common primary causes were antepartum haemorrhage (6.82/1000 births), spontaneous preterm labour (5.33/1000 births) and complications of hypertension in pregnancy (5.19/1000 births). Neonatal deaths due to complications of prematurity and hypoxia were the most common final neonatal causes of death in all groups.
Patient related avoidable factors were reported to be present in 39.3% of perinatal deaths, followed by health worker related (24.6%) and administrative (14.0%). Lack of sufficient information to evaluate the case was present in 5.1% of cases. No, late initiation or infrequent attendance for antenatal care (present in 688 cases) was the most common avoidable factor. This was followed by an inappropriate responses by health workers to problems identified during antenatal care (305 occasions); inappropriate response by patients to poor fetal movements (227 occasions); delays in seeking medical attention during labour (177 occasions); delays in referring patients or calling for assistance (173 occasions); transport delays (162 occasions) and problems of monitoring the fetus during labour (106 occasions).
Conclusion: Concentration on the remedial priority problems identified (namely managing labour, resuscitation of the asphyxiated neonate and care of the premature neonate using Kangaroo Mother Care and the structure of antenatal care) makes the reduction of perinatal mortality in South Africa feasible and inexpensive

Workshop on Women Abuse
Elma de Vries
elmadv@mweb.co.za

Women abuse is a common problem encountered in primary health care. Wifebeating is significantly more common in societies where the status of women is rated as inferior, such as many rural communities in South Africa.
Health workers are not always adequately skilled to recognise and deal with abused women. A recent South African study found that only 15.1% of women, who had a history of abuse, had previously reported such violence to a doctor.
The aims of this workshop are to explore some of the factors that influence women abuse, the difficulties surrounding disclosure, and to assist participants to know how to recognise and deal with women abuse. It will be emphasised that there are different stages that an abused woman goes through, and that we have to respect her own timing. The role of a health worker is to identify abuse, and help the woman realise that it is unacceptable. In the end she is the one who has to decide whether she will leave the abusive relationship.
The format will be an introductory presentation, followed by small-group discussion of case studies, and a role-play.

Working together with women for health
Ms. Temba Dlomo, PHC nurse at Nkonjeni Hospital, South Africa, Mc Master/ University of Natal PHC for Rural Women Project.
Fax no. 035873003

Aim Of The Work:
1.1. To educate women on wider socio-economic issues.
1.2. To educate them to take charge of their own destiny and that of their families.
Scope Of The Work: Educational materials were developed by urban Universities, and rural Primary Health Care nurses were thought how to use these to engage women in an interactive way in primary health care (prevention, promotion and care). Ninety such nurses were trained, and over 500 women became active in 38 groups in one rural area.
The training material covered:

• Empowerment
• Gender sensitivity and human rights
• Using the justice system, including dealing with abuse
• Child development
• Economic empowerment
• Promotive and preventive health
• Caring for people with common and minor illnesses at home

Training took place one afternoon per week for ten months over two years.
The paper describes the project from the perspective of one of the Primary Health care Nurses working in a small rural hospital.
Major Results: The group became a major avenue for information to reach the women, for them to access services and resources, and for nurses to move closer to the communities they serve.
Conclusion: Indigenous rural women in South Africa have been ravaged by poverty, isolation, and lack of education, oppression and heavy social burdens for generations. Changing such a situation to one of community participation in health is a challenge, which nurses in this project have taken up.

Do I really hear what my patient is saying?
Antoinette Struwig, Dept. Family Medicine, University of Pretoria
struwig@med.up.ac.za

The question is asked whether the Health Professional really hears what his/her patient is saying. Do we have the basic communication skills that are needed when a patient comes to me as a professional person for help?
The aim of this interactive session will be to revisit the concept of what good communication is all about. Is the communication process needed for the wellbeing of the doctor or Primary care nurse, or is the primary aim to find out what the patients' need is - those needs that is verbalized and those not verbalized?
Communication and the process surrounding it will be defined and a discussion would be held on the different levels of communication as differentiated by John Powell. Those things that could be a threat to good communication will also be highlighted, and the process of listening will be explored and exercised during an interactive session.
Another aspect of the communication-process, is the management of conflict: why it exists and why it is of utmost importance to find workable solutions for this problem. It can be a stumbling block in a large percentage of relationships where communication can be a problem and will also be addressed during this session.

An Analysis of Transport in the Zululand Health District
Kenneth Kaufmann, Benedictine Hospital, Nongoma, KwaZulu-Natal
klkauf@global.co.za

Transport is important to the success of a health district. First it is one of the major costs drivers consuming at least 10% of the
non-personnel budget. Second without transport health care services cannot be rendered. As part of the training of the Interim Health
sub-District Management Teams in the Zululand Health District, transport management was studied and an analysis of transport in the district was made.
The province uses Form 6 for the monthly fleet reports from each transport pool. An analysis of Form 6 was made as to its strengths and weaknesses. Indicators available from Form 6 include:
1) Need satisfaction
2) Availability
3) Utilization
4) Fuel utilization
5) Fuel cost per kilometre
6) Maintenance Cost per kilometre
7) Fleet running cost per kilometre
A key indicator which was missing was the average kilometres per vehicle. Another problem identified with the form was the utilization of calendar days to calculate availability and utilization. Since most vehicles are only utilized five days per week then utilization appears to be low; and although the target is set lower at 55-70%, when indicators are actually reviewed people tend to regard vehicles which are utilized at less than 70% as underutilized. A further problem involved the definition of workshop and idle. Vehicles which were waiting for authorization to enter the garage and were unuseable were recorded as idle thus falsely and artificially increasing the availability.
Although the form was on the whole very well designed, there seemed to be a problem with managers relating to what the numbers and indicators meant. In an attempt to try and make the transport report more readily interpreted by the managers, Form6 was entered into a spreadsheet with all of the indicators automatically calculated through entering formulas. Also charts were created which automatically illustrated different indicators.
It was hoped that this would make the indicators more meaningful and useful to the managers. It was also hoped that this would make it easier and possible for the transport officers to produce meaningful reports for their managers. However the interim nature of the district health system has made it impossible to get the different transport offices to implement the system to date.
A look at the different indicators and a comparison between different transport pools will be made.

Measuring Quality of Care in a District Hospital - using Lot Quality Assurance Sampling (LQAS) of In-patient notes
B Gaede
besam@futurenet.co.za

Measurement of quality of care is of great interest to managers and clinicians alike, as it is the core product of a health care service. As quality of care is a complex interaction of both objective and subjective components, a variety of approaches would be needed to obtain an integrated assessment. Simple, reliable and rapid methods of measuring different aspects of quality of care of patients are sought.
This paper describes the Lot Quality Assurance Sample (LQAS) method of using a small random sample of in-patient notes in order to assess whether objective targets of quality of care have been reached. The targets are based on indicators that reflect whether certain parameters have been documented in the patient notes. The process of developing and choosing the indicators for assessing quality of care by the sections concerned (medical, nursing, pharmacy and administration) will be described.
Early outcomes of the application of the method based on these indicators at Emmaus Hospital will be presented.
Preconditions for the use of this method will be discussed and a range of applications of the method for quality assurance and supervision in hospital and community settings will be referred to.

A qualitative investigation into the perceptions and motivation of patients requesting circumcision at Kalafong hospital
Smith S, Department of Family Medicine, University of Pretoria
ssmith@kalafong.up.ac.za

Objectives: The objective of this study was to identify and explore the motivations and the perceptions of men who came to Kalafong hospital to request a circumcision.
Method: Men over the age of eighteen who requested a circumcision at the Family Medicine clinic of Kalafong Hospital, qualified for the study. In depth interviews were held with five candidates who agreed to take part in the study. Each interview was recorded on tape. The interviewer, as well as an independent third party took hand written records of each interview.
The interviews were fully transcribed. Themes were colour coded by the investigator as well as an independent co-coder. The main and sub-themes were thus identified.
Results: The main themes identified were the following: Cultural motivations, Improved sexual performance, prevention of sexually transmitted diseases, improved hygiene, to be accepted as a man and fear of the so-called "mountain school".
Conclusion: Many possible misconceptions exist about the potential benefits of circumcision. The most deleterious of these may be the belief that it provides significant protection against sexually transmitted diseases. Further research is suggested to fully explore these themes.

Culture Congruent Care Model: A tool to facilitate rural nurse practitioner training and skills development.
M E Maelane, Lecturer in Nursing Management Course at Pretoria University, Dept of Health Care Sciences
emaelane@postino.up.ac.za

The culture congruent care has been identified as the key Nursing component, to effectively address the health needs of our customers, who are in the majority multicultural and rural in character. Developing and upskilling the practitioners providing services for our clients in this Country, with such a diverse indigenous health care knowledge and practices requires training and development in service delivery, that would be relevant, acceptable and satisfactory to these consumers.
The ability to assess and manage a multicultural client, who is ill or not healthy according to the WHO's definition of health, is recognized as an essential art and skill for the nurse practitioners in fulfilling their expected professional obligation of caring.
Studies have revealed that illness and health is culturally influenced and defined. Therefore, without a profound understanding of ones customer's culture, even when one is to render people focus care, as captured by the concept "Batho-Pele", it will be like imposing a particular foreign health care culture to a group, and hope for it to work perfectly, in addressing the culturally defined illnesses.
The model of culture congruent care, intents to facilitate the introduction of a paradigm shift of nursing care practice for the consumers. In recognition of the importance culture congruent care skills in customer focused nursing practice; Culture congruent care model has been designed to provide training and upskilling of nurse practitioners. With such a model in place, the ambivalences said to have been experienced by the African nurses, in dealing with the culturally-bound syndromes, is hoped to be addressed. The model is a four-tiered one comprising of:
1. Multicultural Team
2. "Afrocentric" Nursing care Practice
3. "Batho-Pele" ( People-First ) Approach and its principles
4. Cultural Competency Approach

Empowerment of rural traditional healers
MD Peu, Lecturer: Dept. Nursing Science, University of Pretoria
mpeu@medic.up.ac.za

Empowerment is crucial in changing the health status of the entire community through the variety of processes. These processes could be in the form of community development projects, basic research as well as educational programmes which could contribute towards the quality of life of all South Africans
The project was established aiming at bridging the gap between health care providers and traditional healers. Various traditional healers participated in the project
The purpose of the project was to:
· Empower the traditional healers with relevant and useful health related information on common conditions in the community of Majaneng.
Various health care providers participated in empowerment of these healers. Different strategies and media were utilized to highlight important areas. The findings of the project indicated that variety of ethical dilemmas were experienced but resolved. The information provided during the workshop proved to be an empowering strategy to the traditional healers and other participants.

The exploration of indigenous health knowledge carried by the older persons in the management of minor ailments of people attending primary care services at Khayelitsha (a community based participatory research).
G Mji, senior lecturer, chair for Center for Care and Rehabilitation
GUMJI@sun.ac.za

INTRODUCTION: The purpose of this project is to explore if the impacting of indigenous knowledge carried by older persons (grandmothers and grandfathers) on health management of minor could enhance appropriate health seeking behavior of people attending two community health centers (CHC's) in Khayelitsha township.
The project developed as a result of over burdening of the CHC's with clients that a majority present with minor ailments. Each CHC's see between three hundred to four hundred clients a day. A mini survey was conducted with results showing 27.5% of the clients from the two CHC's present with minor ailments (Keeran et al, 2000). As a result of overburdening, health care professionals are unable to deal properly with more serious ailments and health education. It seems there is a lack of knowledge for the management of minor ailments at home.
Discussions between the Khayelitsha community, health care providers in Khayelitsha CHC's, and schools of primary care and public and health and rehabilitation sciences of the University of Cape Town continued until a conclusion was reached that raising awareness of the value of indigenous knowledge carried by the older persons in the management of minor ailments at home could be one of the strategies used to change the health seeking behaviors of clients attending the two CHC's and assist in addressing the problem of overburdening of these centers with clients with minor ailments.
Presently the research project has 2x masters students that are funded by National Research Foundation and are in the 2nd year of study.

New model family medicine clinic
Tom Kluyts, Dept. Family Medicine, University of Pretoria
tkluyts@medic.up.ac.za

As a result of various academic discussions between the Family Physicians employed at the Department of Family Medicine at the Pretoria Academic Hospital, and field experience gained by some doctors that did some research work, it was realized that the current model of GP practice, was completely inadequate for use by specialist Family Physicians. We want to propose a model for introduction into practical Family Medicine, which is at the moment being utilized at a rural practice in Namibia. It is foreseen that this could be a very practical re-arrangement of the models currently in use in different levels of Healthcare - from the primary to the tertiary level and can include all medical, para-medical and associated disciplines resulting in a truly holistic, one-stop care-giving facility. This model can, with very few adaptations, be used by a Healthcare provider in any remote rural setting, whilst it can also be used without much alterations, in the most developed and highly equipped Tertiary Hospital. This model differs and is in opposition to the Managed Care concept where the ownership is corporative while in our model the ownership stays in the hands of the Family Physician.

Facing our limitations
Gert Marincowitz
rhinorth@mweb.co.za

The plan is to present the topic in the form of an experiential learning workshop. The purpose of the workshop is to reflect on health workers' reasons for choosing their career (and their desire to help others). The idea is to look critically at our own strengths and weaknesses that urge us to do what we do and to examine the implications of our own needs on the doctor-patient relationship. The aim is to facilitate awareness amongst participants to become aware of our personal benefits in helping others and also to look at possible effects on patients such as the nurturing of dependence, which is contra-productive at the end. The aim is further to examine the issue of personal growth for us as health workers and our patients and with it acceptance of our human limitations. The ultimate would be for participants to work out their own strategy to deal with these challenges and limitations as St Francis of Assisi' prayer describes it: "Lord give us the courage to change the things we can, to accept the things we cannot change and the wisdom to know the difference."

Developing a Diploma in Rural Medicine-what are the components?
Steve Reid
sreid@iafrica.com

The aim would be to get participants' input with regard to what it might look like; what should be included as core and what should be elective; how it could be examined; and where it might be accredited (University, Academy or College). Focus will be on the knowledge and skills required of a rural generalist.

Be At Ease In Emergency Medicine - "FRONTLINER"
Janus Marx, Dept. Family Medicine, University of Pretoria
jssmarx@medic.up.ac.za

Introduction: This workshop is for the colleague who gets a feeling of un-easiness when called to a priority one in the emergency unit.
Structure: The delegates would be challenged with a few case scenarios and hopefully a discussion will follow on triage, initial management and identification of Priority one's This will be followed with practical/physical opportunities to improve the airway, stabilise the C-spine, improve breathing and address hypovolaemia.
Summary: For those who would like to discuss problems in the practice of Emergency Medicine's Platinum 10 minutes and Golden hour and get the opportunity to practice basic techniques

Experiences of a community-based DOTS project in the Eastern Cape Province
Verkuijl S.E.
sabine@hst.org.za

Objectives: To describe experiences with initiating and implementing a community-based DOTS project in the Eastern Cape Province.
Description: Tuberculosis is a major public health problem in OR Tambo District Municipality. The results of the National Tuberculosis Control Programme are poor, with high treatment interruption rates and low successful treatment rates. When funds from a Dutch donor became available a community-based DOTS project was initiated in two rural clinics in the former Lusikisiki sub-district. Ten members of each clinic committee were trained as community DOTS-supporters. They were supplied with bicycles to visit patients and report back to the clinics. The project was officially launched in September 2000. During weekly clinic-visits the team meets with the clinic staff and the DOTS-supporters, attends to patients, provides transport for patients discharged from the hospital, collects sputum specimens, reports sputum results and supplies the clinics with medicines.
This paper will share the experiences of this project and its planned roll-out and report on statistics on case-finding, sputum-conversion and treatment outcome for the first four quarters of the project and compare these with statistics of patients from the same areas over the year 1999.

Pretoria Pasteurization
Bob Pattinson, Kalafong Hospital, MRC Maternal and Infant Health Care Strategies Research Unit, Department of Obstetrics and Gynaecology, University of Pretoria
rcpattin@kalafong.up.ac.za

Pretoria Pausterisation is a novel very inexpensive method of pasterising breast milk to inactivate HIV and other bacteria. The process uses the principle of heat transfer and has been shown to inactivate HIV and keep breast milk sterile for up to 12 hours at room temperature. HIV infected mothers can use the method to give their infants breast milk without the dangers of beast feeding. The process is being successfully used at Kalafong Hospital to feed premature infants of HIV infected mothers.
The presentation will give the relevant data and demonstrate how to use the method pasteurize breast milk.

Are nurses the answer to the health needs of rural Southern Africa?
David Cameron, Principal Family Physician, Department of Family Medicine, University of Pretoria
dcameron@med.up.ac.za

South Africa like many African countries is struggling to provide adequate health care to people living in rural areas. Extending the role of the nurse in the village clinic from prevention and care to diagnosis and treatment is a solution that has been tried in South Africa over the last 20 years. Is this an effective solution? During August 2001 a survey was carried out of the186 nurses who completed the Diploma in Clinical Nursing Science at Jubilee Hospital between 1982 and 2001 to find out what career pathway they have followed and whether the course equipped them for their new role as nurse clinician.
Responses to this survey (77/186, i.e. 41%) showed that 88% felt the course adequately equipped them for their task and had resulted in improved self esteem and confidence in dealing with emergencies. Nearly 60% of respondents are still working in a primary health care clinic. However, a major problem is that the training is not keeping up with the demand. Only 25% of nurses working in the 3 districts nearest to Jubilee have completed the Diploma. In addition, 28% of these trained nurses are planning to leave within the next 2 years. More nurses need to be trained and the difficulties facing nurse clinicians in rural clinics need to be addressed.

AIDS education: the students teaching AIDS to students (STATS) project
Athol Kent, University of Cape Town
atholkent@mweb.co.za

The scourge of HIV/AIDS is affecting the young people of South Africa which has a greater number HIV positive citizens than any other country.
In an attempt to change sexual behaviour, and thereby curb the spread of HIV, a programme has been set up to inform first year medical students about the factual and social aspects of the disease. They volunteer to participate in interactive workshops (called High Five workshops) run by trained students. This enables them to acquire the abilities necessary to inform other young people. Once they are trained they will be asked to go back to the high schools they left the previous year to spread the word and change attitudes.
To achieve this, students are set a questionnaire, attend the workshop and then complete a second questionnaire. This is called the Students Teaching AIDS To Students (STATS) Project and is a randomised control trial studying the impact of the High Five workshops on knowledge, skills and attitudes.
The students come from rural and urban schools and will be transported to these venues once they are competent to instruct their peers. Where rural schools are visited the local medical practitioners will be contacted to assist with these teaching events and become involved themselves.
The aim is to enable school children from all areas to protect themselves from HIV infection. This is the long-term objective of the project.
The willingness of students to become involved and their enthusiasm for the workshop format of learning has been remarkable and will be presented in detail.
The STATS Project has demonstrated that students can successfully teach other students and this results in a cascade of transferable learning skills.

A Health System's analysis of the referral system between the tertiary level ICU's and the peripheral health services KwaZulu- Natal
B R Bhengu, Lecturer, University of Natal; Prof L R Uys, Head, School of Nursing University of Natal
Bhengub2@nu.ac.za

The tertiary ICU's' in the process of transformation in South Africa, have been hard hit financially, by the need to divert the budget to the primary health care institutions in the face of continued demand for ICU's. The coping strategies adopted were stricter ICU admission criteria and early discharge which, necessitates, more emphasis on continuity of care and commitment by the patient to compliance with health advice. However, major disparities between the rural and urban areas have been inherited from the apartheid system. The tertiary health care services are concentrated in the cities while 53% of the population live in rural areas, 75% of whom are poor. The referrals made to distant areas increase problems of infrastructure and cost. This paper will describe a study done between the rural hospitals of one health district in a province of South Africa and the urban tertiary level ICU and Trauma units. The significance of the study is to identify inexpensive strategies to ensure justified referrals, promote compliance, reduce readmission rates and match the health care delivery system with the primary health approach that has been adopted. Results reveal problems of the infrastructure, communication between the referring teams and non- compliance by post ICU patients.

Locally based scholarship scheme in Ingwavuma A replicable solution?
Ross A, Dinath Y, Mosvold Hospital, KwaZulu-Natal
H993393@DOHHO.KZNTL.GOV.ZA

Difficulties associated with recruiting and retaining staff for rural health institutions remain a worldwide problem. International studies show that rural recruitment and interest in working in rural environment expressed early in medical training increase the likely hood of graduates working in a rural area. Mosvold hospital is no exception and over the last decade the hospital has depended heavily upon foreign medical staff to run the service. Since 1998 it has been increasingly difficult to recruit foreign staff. Local studies show a pitifully small number of trained health professionals originate from the region. To ensure the long-term supply of Professional staff at Mosvold Hospital, a partnership between Friends of Mosvold (FOM) and MESAB (Medical Education for SA Blacks) was established in 1997 and the FOM scholarship scheme was launched. To be selected students must:
-come from the sub-district,
-be selected by a resident scholarship committee,
-gain a place in a health science facility,
-do relevant work experience prior to selection,
-sign a work back commitment with Mosvold Hospital.
In 2001 the scheme was expanded to include all the hospitals in the Jozini district. Currently the Scholarship scheme is supporting 31 students across 12 health disciplines and aims to support at least four new students a year. This model - with local student selection, an ongoing relationship between the student and the service provider, mentoring and support at the university, and a defined role within the health care team; can provide a model for other rural area's in recruiting and training of professional staff.

Emergency treatment of hand injuries
Edward Bowen-Jones
ebjones@mweb.co.za

Hand injuries are common affecting all ages, both genders arising in the home, at work, and in accidents on the road. Whilst a Rural Doctor would not be expected to perform intricate repairs, he will frequently be called upon to provide the primary treatment and on this may depend the final outcome. All doctors in emergency care should understand how to asses a hand injury, provide appropriate emergency treatment, perform simple repairs (e.g. suturing) themselves and know when and where to refer patients for further treatment.
Hands may suffer clean cuts, bites, crushing, shearing, avulsion, twisting, bending, abrasion, explosion and burn injuries and amputations. With the exception of vascular injuries and amputations for microvascular reimplantation which require urgent transfer, most injuries can wait a day or two for definitive treatment if adequate emergency surgery has been done in the rural hospital.
Initial assessment includes a detailed history, examination and X-ray. The clinical signs of tendon, nerve and ligament injury will be discussed. If tendon or nerve injuries have been caused by clean cuts, the skin should be sutured and the patient referred for delayed primary repair.
If there are crushing, abrasion, de-gloving or explosion injuries, especially if the wound is contaminated, the patient should be taken to theatre within a few hours for a thorough clean under an anaesthetic. Obviously dead tissue debrided, dirt and foreign bodies removed, and the limb dressed with an antiseptic, absorbent and non-adherent dressing and splinted with plaster of Paris in the correct position. A powerful antibiotic and tetanus prophylaxis given and the patient is referred for a definitive repair to a hand surgery unit.
Small grafts on fingertips, simple extensor tendon injuries and simple fractures may be managed totally in the rural hospital. Details will be given on such simple procedures and cautions such as human bites.
Finally, early mobilisation and correct splinting, essential for functional recovery will be discussed.
The Rural Doctor plays a vital role in the successful treatment of all hand injuries passing through his care.

A study of pedigree families suspected with familial adenomatous polyposis (FAP)
W Lubinga, Principal Medical Officer, Donald Fraser Hospital.
wlubinga@worldonline.co.za

OBJECTIVE: To screen members of pedigree families for colorectal polyps and colon cancer by colonoscopy.
STUDY SETTING: Donald Fraser hospital, a rural district hospital in Northern Province, South Africa.
BACKGROUND: Eighteen pedigree families with >465 family members excluding >135 spouses; 15 deaths from colon cancer and 7 members done total proctocolectomy for adenomatous colon polyps. No colon cancer screening program exists for this pedigree at the hospital. No member of this pedigree has had genetic testing.
SUBJECTS & METHODS: Persons with >50% risk of having colon polyps based on family history qualified for inclusion into the study. They were invited for clinical examination for extracolonic manifestations of FAP and colonoscopy.
RESULTS: Seventy-seven persons met inclusion and exclusion entry study criteria; seven persons had FAP and seventy persons were eligible for screening colonoscopy. Thirty-three (47%) persons were screened for colon polyps. Colonoscopy revealed two new related persons (6%) with colon polyps. One had four benign adenomatous polyps and the other had eight adenomatous polyps, one of which showed severe dysplasia but none were malignant. These two persons declined colorectal surgery despite appropriate counselling.
CONCLUSIONS: The pedigree has familial colon cancer syndrome. Family members need to regular screening for colon polyps. Genetic testing will establish the genetic basis of the familial colon cancer syndrome and guide the screening colonoscopies target only persons with the genetic trait.

Improving the emotional intelligence of the medical practitioner in order to provide him with important personal and social skills.
Ronél le Roux and Rina de Klerk
ronellr@vouzi-isp.co.za

In an hour's presentation by Drs. le Roux and de Klerk delegates can be made aware of some of the most important knowledge and skills an individual should have to understand and cope with his and other people's inner functioning. The aim with our presentation will be to increase the awareness of delegates in making careful decisions about their own functioning and their relationship with others. At the end of our presentation we want delegates whom:
1. Are able to recognise their own feelings, thoughts, assumptions and perceptions;
2. Can identify and control their intense feelings and cope with them appropriately without harming themselves and others;
3. Can communicate with other people, have empathy with them and who can recognise and accept the perspectives of others;
4. Are capable to cope meaningfully with most social situations;
5. Can follow a balanced lifestyle.

It is increasingly acknowledged that the above-mentioned skills and knowledge are even more important than intellectual and technical skills in the meaningful functioning of an individual in all relationships. Students and doctors can develop and function optimally as professionals and in other areas of their lives when they are given the additional life skills needed.

In our presentation we will use interactive methods that will leave the delegates with a greater awareness of their own emotional intelligence and they will learn some personal and social skills that they can start using immediately.