Thesis (MFamMed)--Stellenbosch University, 2014. / BACKGROUND:Family physicians are trained to enable them to staff community health centres and primary care hospitals. Part of this training is teaching them procedural skills for anaesthetics and surgery. Knysna hospital is a training facility for family medicine registrars and this article aims to evaluate if sufficient learning opportunities exist in Knysna hospital’s theatre to teach family medicine registrars procedural skills. METHODS:A descriptive study was undertaken of the number and type of procedures performed in Knysna hospital theatre for a one year period, and compared with the required skills,as stipulated in the national training outcomes, for the discipline. RESULTS:Three thousand seven hundred and forty one procedures were performed during the study period. Anaesthesia was the most common procedure, followed by caesarean section. There were adequate opportunities for teaching most core skills. CONCLUSIONS: There were sufficient opportunities for a registrar to be taught all the core skills that are exclusive to theatre. Further research is needed to evaluate Knysna hospital as a training facility for all procedural skills. / AFRIKAANSE OPSOMMING: Geen opsomming beskikbaar.

Introduktion: Multipel Skleros [MS] är en autoimmun nervsjukdom som påverkar kroppens alla funktioner, genom att nervernas ytskikt, myelin, skadas och bryts ner. Orsaken är okänd och sjukdomen anses vara kronisk, då det i nuläget inte finns något botemedel. Sjukdomen upplevs olika av alla och genom att belysa erfarenheter hos personer med MS, kan sjuksköterskan få en större förståelse för personers situationer och på så vis kunna anpassa vården efter olika behov. Syfte: Litteraturstudiens syfte var att belysa personers erfarenheter av Multipel Skleros. Metod: Litteraturstudien grundades på Polit och Becks (2017) niostegs flödesschema. Sökningar genomfördes i databaserna Cinahl och PubMed. Urval i tre steg och databearbetning genomfördes, vilket resulterade i 15 kvalitativa artiklar. Resultat: Fyra huvudkategorier identifierades: MS – en känslofylld resa, Stöd & relationer, Planera för att vara aktiv och Att bilda familj – från ett kvinnligt perspektiv. Slutsats: Personer med MS upplevde att vägen fram till diagnos var lång och fylld av många olika känslor. Personer med MS ansåg att sjukdomen innebar en ständig kamp att anpassa sig till det vardagliga livet, där stöd och sociala relationer var en stor och viktig del.

La consommation élevée de psychotropes en France, l’ampleur des enjeux médico-sociétaux des maladies neurologiques et psychiatriques et les projections de population en termes de vieillissement soulignent toute l’importance d’une mobilisation des acteurs de santé. Le dispositif sanitaire français se caractérise par le rôle clé du médecin généraliste(MG) notamment pour la prise en charge des patients sous traitements de substitution aux opiacés(TSO) ou encore des personnes âgées vulnérables, justifiant que ce travail de thèse ait porté spécifiquement sur ces deux problématiques. Dans une première partie, nous avons analysé les caractéristiques des sujets sous TSO vus par les MG d’après une enquête OPEMA. L’importance d’une analyse fine des consommations via des tests rapides de dépistage urinaires des toxiques a conduit à une étude multicentrique ESUB-MG en cours. Lors de ces deux travaux, une démarche de synthèse sur la contribution du MG dans le repérage du trouble de l’utilisation de substance et dans l’Addictovigilance a été initiée. Dans une deuxième partie, nous avons analysé l’intervention du MG dans la prise en charge d’une population âgée vulnérable (Cohorte PACA-Alz). Nous avons étudié l’exposition aux antipsychotiques, puis la prévalence de l'utilisation d'antipsychotiques à long terme. Enfin nous avons voulu identifier les typologies d’exposition aux antidépresseurs chez les plus de 65 ans. L’ensemble de ce travail de thèse a permis: de confirmer le rôle clé du MG dans le dispositif sanitaire français; de souligner son implication dans le mésusage et leurs conséquences au sein de ces deux populations étudiées; de souligner sa contribution à leur prévention. / The high level of psychotropic drugs consumption in France, the extent of the medical and societal challenges of neurological and psychiatric diseases, and population projections in terms of aging, emphasize the importance of mobilizing health care stakeholders. The French healthcare system is also characterized by the key role of the general practitioner(GP), particularly in the treatment of patients under opioid substitution treatment(OST) or vulnerable elderly people, the reason why this thesis work specifically focused on these two aspects. During the first part of the study, the characteristics of subjects under OST observed in general medicine have been analyzed according to a national survey(OPEMA). The importance of a precise analysis about the consumption through urine drug screening test, led to a cluster randomized study ESUB-MG in progress. In these two studies, a synthesis approach was initiated to look for the contribution of the GP to the identification of the substance use disorder and Addictovigilance. Secondly, the intervention of the GP in the management of a vulnerable elderly PACA-Alzheimer cohort has been analyzed. The exposure to antipsychotics has been studied, then the prevalence of long-term use of antipsychotics. Finally, patterns of adherence to antidepressant treatments in patients over 65 years old have been identified. The whole of this thesis work allowed: to confirm the key role of the GP in the French health system (including health vigilance systems); to highlight its involvement in the misuse of psychoactive drugs and their consequences within the two populations that were studied; to emphasize the its contribution to their prevention.

The increase in certified sickness absence recorded in most European countries during the last decade is of increasing concern to public health agencies. While sickness absence can promote rest and recovery from illness, it may also have negative consequences, including increased risks of inactivity and isolation, poorer quality of life and increased uptake of health services. In the Republic of Ireland (ROI) sickness certification is part of General Practitioners’ (GPs’) contractual service to the Department of Social Protection (DSP). Sickness certificates are also issued to patients as evidence of illness for employment purposes. There is limited research exploring GPs certifying practices in the Republic of Ireland. The aim of the thesis was to explore perspectives on sickness certification in general practice in Ireland. The data collection consisted of three stages. Study 1 consisted of in depth individual interviews with 14 GPs across 11 primary care practices in Ireland. Study 2 was based on an on-line questionnaire survey using a number of vignettes with 62 GPs working in primary healthcare. Finally, study 3 consisted of a focus group conducted with eight GPs in a large urban practice in Ireland. Qualitative analysis was conducted in vivo using content and simple thematic analysis techniques. Quantitative data was analysed by descriptive and inferential statistics using PASW version 18 statistical software. Combined results indicate that GPs can find their role as certifiers’ problematic and a source of conflict during the consultation process with patients. GPs concerns are with breaching patient confidentiality and in particular disclosing illness to employers. They reported feeling inadequate in dealing with some cases requesting sickness leave, including certification for adverse social circumstances and they felt a need for better communication between themselves, employers and relevant government departments. Willingness to issue a sickness cert may be influenced by the nature of the patient’s presenting problem. A psychological problem generated greater belief that patients were unfit for work, and GPs were more sympathetic and showed greater satisfaction with the decision they had made to certify these patient in comparison to patients with a physical problem. Average sickness certification periods were longer in cases of psychological nature (1-2 weeks) in comparison to the physical complaint (4-7days). Overall GPs displayed a negative feeling towards prescribing sickness leave and there was a perception that sickness certificates were being used by employers as a management tool in controlling absenteeism. GPs also mentioned cultural factors in work place absenteeism and lack of rehabilitative pathway as impacting on sickness certification practices in Ireland. Issuing a sickness certificate appears influenced by medical and non-medical factors. Potential exists for improving the system, but requires significant engagement with other stakeholders such as employers and social benefit agencies. Focus should be placed on referral and rehabilitative pathways for patients to ensure appropriate certification and early return to work.

Background: Inequity in general practice workforce distribution remains a significant issue despite the increasing numbers of general practitioners (GPs) in the UK. Problems with recruitment and retention in England are particularly evident in urban deprived areas. The aim of the current study was to explore affinity for working in urban deprived areas, focusing on practitioners’ background, values and care orientation. Methods: There were two stages to the research: 1) semi-structured qualitative interviews with 25 GPs and practice nurses to explore their background, values and care orientation in relation to location; 2) questionnaire survey with approximately 1200 GPs and practice nurses to determine the association between affinity factors and current location. The sample of practitioners was drawn from general practices located in the most and least deprived areas in the northwest region of England. Results: 25 qualitative interviews were conducted and the data analysed using a framework analysis approach. The analysis indicated that location preferences were formed early in practitioners’ careers. While an overt affinity for deprived areas was more likely among GPs, pragmatism could dominate location decisions for all. The narrative of practitioners in deprived areas suggested benevolent, universalistic and stimulation personal values, and a patient-centred care orientation. Satisfaction derived from making a difference, having a challenge, addressing social injustice, and having a sense of belonging. Coping strategies included: structure and organisation, support from colleagues, emotional detachment, reassessment of expectations, and distraction. The response rate to the postal questionnaire survey was 30.9% for GPs and 41.2% (practice level) for nurses. Although there were few differences in the personal values of practitioners working in deprived and affluent areas, there were more differences in specific work values. Stepwise logistic regression showed that for GPs, determinants of working in a deprived area included: having trained in a deprived area; not being influenced by the convenience of the location in choosing their current practice; and valuing control in decision-making. For nurses, determinants included: having worked in a deprived area before; not being influenced by quality of care in the practice when choosing their current practice; and not valuing being respected by practice colleagues. Subgroup analyses suggested different predictors for practitioners with different role status: GP principals were more likely to work in a deprived area if they valued providing care to those in greatest need of help, in addition to having trained in a deprived area. Discussion: The training location of GPs was a consistent factor in determining current location. This differs from the literature on location choice in rural and remote areas, for which childhood exposure is considered to be the dominant factor. Differences in personal values were reflected more clearly in specific work values. Future research should look at how GPs choose their training practice and how such experiences could be exploited to enhance recruitment to underserved urban areas. Strategies to aid retention could look to the coping strategies employed by practitioners to deal with the demands of working in a deprived area.

The study was designed to explore the proposition that conduct of and participation in research by general practitioners in British Columbia would be both desirable and feasible. Desirability was defined in terms of benefits for knowledge, for the medical practice, and for society at large. Feasibility was defined in terms of being acceptable for the general practitioner, for the patient, for the practice, and for the requirements of research. To answer specific questions related to desirability and feasibility of research by general practitioners, information was obtained from the literature, from a questionnaire survey of the total general practitioner population of British Columbia, and from a random sample of patients in practices selected at random from respondents to the questionnaire to general practitioners. In the survey of general practitioners, 2,344 questionnaires were mailed. Of the 563 (24%) which were returned, 508 were available for analysis. Five were returned by the post-office undelivered, seven were too late for analysis, and forty-three were returned with information indicating that the respondent was not in general practice. Forty- eight respondents were anonymous, and the remainder identified themselves. The response of general practitioners represented a variety of geographic locations, ages, types of practice, and medical schools. Members of the College of Family Physicians of Canada had a response rate of 39%. In the survey of patients, 15 out of 20 general practitioners who were contacted agreed to submit questionnaires to their patients. Of the patients surveyed, approximately 90% completed the questionnaires. Most were regular patients of the doctors, and represented a full range of ages, and both sexes. General practitioners and their patients agreed that research by general practitioners was desirable, and suggested many areas suitable for research. The benefits of research to the general practitioners, patients, and society were considered to be incentives, encouraging research activity. Important among the benefits were the discovery of new knowledge and the contribution to the academic base of general practice. The feasibility of research was explored in terms of the conditions required for its conduct. Attitudes were receptive to the concept of research, as many of the general practitioners had previously been involved in projects. Major deterrents were heavy workload and lack of time, for the general practitioners, and in their practices the high overhead and pressure of work on the staff were problems. Training for research was variable, with some general practitioners having none and a few having much training. Inadequacy of the usual office records was recognized, so that research would usually require special methods. General practitioners had little awareness of resources available for help, advice or financing, but most were aware of the need for such resources. Patients were willing to cooperate in studies. They suggested that the cost of research should be borne primarily by governments, and to a lesser extent by foundations and the public. Recommendations were made for the support of research, to help overcome the problems which decrease its feasibility. There should be encouragement of training in research methods, at both undergraduate and postgraduate levels. This would include presentation of research findings to scientific meetings of medical societies, and visits to and from eminent research workers in general practice. Some assistance should be given to the general practitioners, such as help in developing office records for research or payment for time spent on research. Resources for help in planning studies and processing results should be readily available, including both consultant advice and the provision of grants. Conclusions from the study were that research by general practitioners in British Columbia is desirable, and that it is feasible but has several major deterrent factors which can inhibit research activity. Because of these factors, the great potential for research in British Columbia is still far from being realized. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

L’épidémiologie des diarrhées aiguës (DA) hivernales a été peu décrite chez l’adulte. Ces DA sont principalement dûes à des virus entériques. Des virus influenza peuvent être détectés l’hiver dans les selles de patients grippés présentant des signes digestifs, mais on ignore s’ils peuvent être retrouvés chez des patients présentant exclusivement des troubles digestifs. Durant les hivers 2010/2011 et 2011/2012, les médecins Sentinelles (Inserm-UPMC) ont inclus 192 patients adultes consultant pour une DA et 105 patients contrôles. Un prélèvement de selles était effectué pour la recherche de norovirus (génogroupes I et II), rotavirus du groupe A, adenovirus entérique humain, astrovirus et virus influenza A(H1N1)pdm2009, A(H3N2) et B. Durant les hivers étudiés, l’incidence moyenne des DA chez l’adulte a été estimée à 3158 pour 100 000 adultes (IC 95% [2321 – 3997]). Un traitement était prescrit pour 95% des patients avec une DA, et un arrêt de travail pour 80% des patients actifs. Les examens de selles ont permis de détecter un virus entérique chez 65% des patients diarrhéiques, le plus souvent un norovirus (49%). Parmi les patients présentant une DA, 7,2% étaient positifs à un virus influenza, ces derniers n’ayant pas rapporté de signes respiratoires. Les symptômes décrits par les patients diarrhéiques adultes ne différaient pas en fonction de la présence ou absence d’un virus entérique. Les patients contrôles ne présentaient ni virus entériques ni virus influenza dans leurs selles. Aucun facteur risque évitable n’a été identifié, autre que le contact avec une personne malade au sein du foyer et/ou en dehors, rapporté chez 46,2% des patients ayant consulté pour une DA. / The epidemiology of winter acute diarrheas (AD) has not been described in adults. These AD are mainly due to enteric viruses. In winter, influenza viruses can also be detected in stools of influenza patients with digestive signs, but we don’t know if these viruses can be found in the stools of patients suffering from digestive disorders exclusively. During the 2010/2011 and 2011/2012 winters, general practitioners (GPs) from the Sentinelles network (Inserm-UPMC) included 192 adult patients consulting for an AD and 105 control patients. Stool samples were collected and tested for norovirus (genogroups I and II), group A rotavirus, human enteric adenovirus, astrovirus and influenza viruses A(H1N1)pdm2009, A(H3N2) and B.During the studied winters, the average incidence of AD in adults was estimated to be 3,158 per 100,000 adults (95% CI [2,321 – 3,997]). GPs prescribed a treatment in 95% of the patients with AD, and 80% of the working patients with AD could not go to work. Stool examinations were positive for at least one enteric virus in 65% of cases, with a predominance of noroviruses (49%). Of the patients suffuring from an AD, 7.2% tested positive for one influenza virus, none reported respiratory symptoms. Among the patients with AD, the reported clinical signs did not differ between adults with a virus in the stool sample and those with no virus found in the stool exam. None of the controls tested positive for one of the enteric and/or other influenza viruses.No preventable risk factor was identified, other than the contact with a sick person within and/or outside the household, reported by the patient in 46.2% of cases.

Le paiement à la performance (P4P) appliqué aux soins ambulatoires a vu le jour dans les années 2000 dans les pays anglo-saxons et a connu un fort développement ces dix dernières années. Il a été introduit en France sous forme optionnelle au travers des Contrats d’Amélioration des Pratiques Individuelles (CAPI) en 2009, puis généralisé en 2012 avec la Rémunération sur Objectifs de Santé Publique (ROSP). Son principe consiste à allouer un surcroît de rémunération aux médecins en échange d’une meilleure qualité de leur pratique, celle-ci étant mesurée à partir d’une batterie d’indicateurs. Les principes de justice et de bienfaisance qui pourraient se voir renforcés dans ce cadre, semblent mis en tension avec le principe d’autonomie, le P4P pouvant être considéré comme un outil supplémentaire visant à normaliser les pratiques médicales tout en renforçant l’exclusion de toute singularité. Nous avons d’abord interrogé les médecins généralistes sur la notion de norme médicale. Ils ont semblé s'accommoder du concept sans exprimer le besoin de le préciser. Ils avaient le sentiment qu'une normalisation stricte de leur pratique était impossible. Les considérations éthiques, élevées en pare-feu, ont structuré leurs déclarations. Nous avons ensuite analysé la nature des freins à la signature du CAPI auprès d’un panel de plus de 1 000 médecins généralistes. Nous avons identifié deux profils de médecins : ceux percevant les risques éthiques comme étant globalement faibles et acceptant de signer (31,7%) et ceux les percevant forts, refusant de signer (68,3%). L’absence d’information des patients concernant l’adhésion de leur médecin au CAPI était le principal risque perçu par les non-signataires. Puis, nous avons étudié l’impact du P4P sur une variable associée à la qualité des soins : la durée de consultation. Notre principal résultat était que le CAPI n’a pas eu un impact significatif sur la durée de consultation. Enfin, nous avons interrogé directement des patients. Leur avis était très partagé, d’aucuns considérant que l’attribution d’une prime pourrait améliorer certaines pratiques comme la prévention et le dépistage, d’autres étant fondamentalement hostiles à ce principe qu’ils estimaient aller à l’encontre des valeurs du soin. / Pay for performance (P4P) applied to outpatient care has emerged in the 2000s and has experienced strong growth over the past decade. It was introduced in France under optional form through the Improvement of Individual Contracts Practice (CAPI) in 2009 and was generalized in 2012 with the Compensation on Public Health Objectives (ROSP). Its principle is to allocate additional compensation to doctors in exchange for a better quality of their practice, the latter being measured from a set of indicators. The principles of justice and beneficence that could be strengthened in this context seem in tension with the principle of autonomy. P4P can be regarded as an additional tool to standardize medical practices while reinforcing the exclusion of any singularity. We first asked general practitioners on the notion of medical standard. They appeared to live with the concept without expressing the need to clarify it. They felt that a strict standardization of their practice was impossible. The ethical considerations have structured their statements. We then analyzed the nature of the obstacles to the signature of CAPI from a panel of over 1,000 general practitioners. We identified two profiles of doctors: those feeling ethical risks as generally low and agreeing to sign (31.7%) and those perceiving them strong, refusing to sign (68.3%). The lack of patient information concerning the adherence of their doctor to a P4P contract was the main risk perceived by the non-signatories. Then, we investigated the impact of P4P on a variable associated with the quality of care: the consultation length. Our main result was that the CAPI has not had a significant impact on the consultation length. Finally, we interviewed patients directly. Their opinion was very divided, some thought the allocation of a bonus could improve certain practices such as prevention and screening, others being fundamentally hostile to this principle they considered going against the values care.

This thesis is devoted to general practice (GP) networks in Belgium, their development and their activities within the Belgian health system context. These networks are specific research tools for the repeated or continuous collection and analysis of data related to diseases and other health events observed in general practice, including interventions of general practitioners. The thesis focuses on three not-for-profit general practice research networks which are operational today: (1) the national Network of Sentinel General Practices (SGP), coordinated by the Federal research institute Sciensano; (2) the Flemish Intego network, coordinated by the Academic Center for General Practice of Catholic University Leuven; (3) the network of the Fédération des maisons médicales et des collectifs de santé francophones (FMM) with its Monitoring Chart (Tableau de bord), which collects data from Wallonia and the Brussels-Capital Region. The thesis is divided into a general introduction, three main parts and a final discussion with concluding remarks. The general introduction outlines the importance of data from general practice and the contribution of GP networks to research. Furthermore, it points out the importance of general practice for the control of sexually transmitted infections (STIs), a specific field of action. The first main part of the thesis investigates the research question of how the three GP research networks developed within the specific context of the Belgian health system. It is based on the interpretation of written sources such as project reports, annual network reports, research publications, parliamentary documents, relevant websites and the existing research literature. The context analysis included a comparison with the Netherlands since the latter have strong traditions with regard to the position of the general practitioner in the health system (gatekeeper to secondary care, whereas in Belgium the patient generally chooses his/her health provider, and a Global Medical File administered by the general practitioner is not mandatory in Belgium), to general practice research networks and computerisation. It could be shown (1) that Belgium has held a middle position in the European Union regarding GP computerisation; (2) that, contrary to the Netherlands, an operational national GP network based on data from electronic health records (EHRs) could not be established; and (3) that Belgian health system computerisation, which advanced substantially in the last decade, put the issue of health data collection and storage by a new digital service on the agenda. Subsequently, three sub-chapters focus on the development of the three GP networks from their foundation until today. They demonstrate that the SGP and Intego were founded as innovative tools originating from Flemish general practice research, whereas the Monitoring Chart originated from the dynamism of Integrated Primary Health Care Centres (IPHCCs, Maisons médicales) in French-speaking Belgium. Acting as health observatories was both part of the mission of the IPHCCs and the demand of the Regional governments. With time, the research designs of the three GP networks became more sophisticated. Furthermore, European cooperation of the SGP with other GP networks since the late 1980s stands out, since the vision to establish a European sentinel general practice network led to joint influenza surveillance as one of its lasting achievements. In continuation of the developments described above, the second main part of the thesis addresses the missions and the organisation of the three GP networks today as well as their respective strengths and limitations in comparative perspective. It is based on network publications and reports, relevant websites and informal information from the networks themselves. The comparison shows that there is little overlap between the activities of the three GP networks, given the different areas of investigation and the complementarity of supplementary information collected by the SGP versus routine data extraction from EHRs in the other two networks. Furthermore, Intego and the Monitoring Chart essentially cover different parts of the country. The prospective research design of the SGP allows formulating hypotheses and designing research questionnaires with precise definitions of diagnoses before the start of a new research topic in order to minimise inter-observer variability, whereas the diagnosis in the other two networks is the result of the general practitioner's clinical judgement. The Intego network disposes of a substantial number of routine parameters collected over more than two decades by now. With these data, the researchers can design retrospective cohort studies without recording or recall bias by the GP who does not know during his/her daily routine for which research questions his/her data may be used later. The Monitoring Chart stands out by its comparatively strong presence in the Brussels-Capital Region and its data from the less well-to-do part of the population. The third main part of the thesis focuses on STIs which provided a research opportunity, given that Belgian public health efforts to control them have increased in recent years and that the three GP networks engaged in research activities in this regard. The first sub-chapter addresses challenges for the surveillance and monitoring of STIs due to the nature of the pathogens, followed by a sub-chapter about characteristics of STI surveillance and monitoring in Belgium. Afterwards, a sub-chapter describes health policy efforts in order to establish the Belgian HIV Plan 2014-2019. The development of the HIV Plan was analysed by applying the policy streams model of John Kingdon. The analysis was based on published government statements, parliamentary documents, and websites of stakeholders, and showed that the Federal Ministry of Health initiative to achieve the HIV Plan was characterised by a coordinating role with a participatory approach towards the other Belgian governments and stakeholders. The 2013 protocol agreement of the Belgian governments committed them to principles, actions, and cooperation regarding HIV prevention, testing, treatment of persons living with HIV and care for their quality of life, but not to budgets, priorities or target figures. The implementation of the plan, highlighting aspects relating to general practice, is addressed in the subsequent sub-chapter. Two further sub-chapters are based on the analysis of retrospective cohort studies with Intego data from 2009 to 2013, based on EHR routine registration by over 90 general practitioners in Flanders. In the first sub-chapter, the frequencies of gonorrhoea and syphilis diagnoses were investigated. Case definitions were applied. Due to small case numbers obtained, cases were pooled and averaged over the observation period. Frequencies were compared with those calculated from mandatory notification. A total of 91 gonorrhoea and 23 syphilis cases were registered. The average Intego annual frequency of gonorrhoea cases obtained was 11.9 (95% Poisson confidence interval (CI) 9.6; 14.7) per 100,000 population, and for syphilis 3.0 (CI 1.9; 4.5), respectively, while mandatory notification was calculated at 14.0 (CI: 13.6, 14.4) and 7.0 (CI: 6.7, 7.3), respectively. In spite of limitations such as small numbers and different case definitions, the data suggests that the general practitioner was involved in the large majority of gonorrhoea cases, while the majority of new syphilis cases did not come to the knowledge of the general practitioner. The second sub-chapter deals with the prescription of antibiotics to treat gonorrhoea in general practice in Flanders 2009-2013. Belgian guidelines recommended ceftriaxone or alternatively spectinomycin from 2008 onwards and azithromycin combination therapy since 2012. The study investigated to which extent contemporary gonorrhoea treatment guidelines were followed. Ninety-one gonorrhoea cases with ten chlamydia and one genital trichomonas coinfections in 90 patients were registered between 2009 and 2013. The proportion of cases with ceftriaxone and/or spectinomycin prescriptions rose from 13% (two of 15 cases) in 2009 to 56% (nine of 16 cases) in 2013. Combination therapy of ceftriaxone and/or spectinomycin together with azithromycin rose from 0 of 15 cases (0%) in 2009 to 7 of 16 cases (44%) in 2013. Although numbers are small, the results suggest that gonorrhoea therapy guideline adherence improved between 2009 and 2013. Future opportunities, recommended in the final discussion, include (1) extending provider-led STI testing in Belgium, with a prominent role for general practitioners; (2) investigating barriers and facilitators for the achievement of the Global Medical File, notably if sensitive and potentially stigmatising issues such as STIs or mental health are involved; (3) making task delegation by the general practitioner towards other primary health care providers more attractive; (4) facilitating general practitioners' tasks by the introduction of support features into the EHR in order to improve registration and quality of care in general; (5) eliciting Regional government support in order to investigate the diagnostic profiles of the patient population of IPHCCs; and (6) establishing an extended network for the collection and analysis of "production data" (such as the number of contacts, interventions, referrals, prescriptions and diagnostic requests) from general practitioners and other primary health care providers, proceeding from the know-how and the experience of the three investigated GP networks. / Doctorat en Sciences de la santé Publique / info:eu-repo/semantics/nonPublished

Objective: The objectives of the study were to determine General Practitioners' attitudes to National Health Insurance (NHI) and to capitation as a mechanism of reimbursement. The study also aimed to explore determinants of these attitudes. Design: The methodology utilised a cross-sectional survey using telephone interviews and four focus group discussions. Setting: The study area was the Cape Peninsula area in the Western Cape Province of South Africa. Participants: 174 general practitioners (GPs) were randomly sampled from a total population of 874 GPs in the Cape Peninsula area. Main outcome measures: The main outcome measures were GPs' acceptance of NHI and of capitation as a method of reimbursement. Main results: Sixty three percent of GPs (63,3%) approved of NHI. More than 81 % approved of NHI if GPs were to maintain their independent status, for example their own premises and working hours. Eighty two percent (82,3%) said NHI would be a more equitable system of health care than the system that existed at that time, 88% approved of the fact that NHI would make care by GPs more accessible and 73% said they had the capacity to treat more patients. However, 61,3% of GPs disapproved of capitation as a form of reimbursement. The most common conditions cited by GPs for support of NHI were retention of professional autonomy, fee for service reimbursement and adequate levels of reimbursement. Conclusions: Most GPs in the Cape Peninsula were amenable to some form of NHI. However, approval of NHI is to some extent conditional to details of the NHI system, such as payment mechanisms, workload, income and effects on professional autonomy. The implications of GPs' preferences concerning the reimbursement mechanism for the feasibility of implementing a NHI in South Africa requires serious consideration by policy makers. While this research demonstrates broad ideological and conceptual support for some form of NHI or SHI, further research is required to provide more detailed quantitative information on the trade-offs that GPs would be prepared to make for them to support the introduction of a new socially based insurance system. A national survey of medical practitioners is recommended.