CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
AFRICA
189
management of their patients, patient care is not always optimal.
Availability of increased numbers of senior doctors and special-
ists who provide outreach may go a long way in ameliorating
some of these challenges.
Another disconcerting finding in this study was the obser-
vation that most doctors were unable to name the compelling
indications for hypertension treatment or failed to list the correct
treatment when given a list of these conditions. This demon-
strates that there is a need for ongoing education of doctors
about management of conditions with important public health
implications, such as hypertension. The publication of guidelines
is an important way of developing minimum standards for coher-
ence and uniformity in treatment of clinical entities. However, as
demonstrated in this study, the prominent display of guidelines
in hospital corridors and consulting rooms does not equate to
physician knowledge.
An interesting question that arises from this study is: how
can primary health practitioners who treat one of the most
common conditions in their practice, hypertension, be unfamiliar
with or ignorant of the latest guidelines? There is a perceived,
and perhaps real disconnect between experts (who are mostly
academics) who write guidelines, and primary healthcare doctors
(who are expected to implement guidelines and improve health
of the population), with limited opportunities for engagement
between the two groups.
After publication of guidelines, dissemination of the message
to the relevant doctors is of paramount importance. Publication
in journals and posters is clearly not sufficient. Multi-pronged
implementation and education programmes need to be devel-
oped. Others have demonstrated that education alone is not
enough to change physician behaviour, and that the process of
change is more related to attitude.
15,16
In other parts of the world, where there is also poor imple-
mentation of hypertension guidelines by primary health doctors,
authors have demonstrated that hypertension clinical guidelines
are often regarded as optional rather than standards, and many
doctors feel that the recommendations are not suitable for their
patients.
17
While it is not clear if such attitudes are also operation-
al in our small sample of doctors, it is clear that multi-dimension-
al risk stratification and intervention is too time-consuming for
doctors who are already overwhelmed by the workload of patients.
An important aspect of this study was the examination
of factors that impact on the ability of public-sector primary
healthcare doctors to effectively treat hypertension. In the main,
these challenges were related to reported poor adherence to
treatment by patients, communication difficulties due to doctors
not speaking the language of the patients, and heavy patient
load in the context of significant shortage of both nurses and
doctors. A further challenge elaborated on by the doctors is the
fact that many patients regularly move between the Eastern Cape
and Western Cape provinces, with the consequence of regular
patient loss to follow up. High levels of poverty and illiteracy
were also mentioned as factors that hamper effective care of
patients. Drug shortages and lack of functional equipment are
problems that also emerge, from time to time, to affect care of
patients with hypertension and other chronic co-morbidities.
Systematic factors, including financial restrictions on investiga-
tion of patients at the primary level of care were also mentioned
by some of the doctors.
Interestingly, in a different study by Steyn and colleagues,
conducted in a random sample of 18 CHCs in the Cape Town
area, the authors similarly found that staff shortages, complex-
ity of cases previously managed in tertiary hospitals and lack of
financial resources for special investigations were reported by
healthcare workers as significant impediments to their care of
patients with chronic conditions.
18
Conclusion
This study demonstrates that the majority of doctors treating
hypertension in the primary health clinics are fairly junior, and
significant gaps exist in their knowledge regarding management
of hypertension. Awareness of the South African hypertension
guidelines should be improved. Furthermore, an urgent, concert-
ed, multi-sectorial effort to address the challenges to effective
care of hypertensive patients at a primary level of care is needed.
The investigators thank the patients and staff based at Gugulethu Community
Health Centre and Khayelitsha Site B Community Health Centre. The
research reported in this study was not funded. Dr Ntusi receives funding
from the Discovery Foundation and the Medical Research Council of South
Africa.
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