|Year : 2019 | Volume
| Issue : 3 | Page : 184-190
An opportunity for intervention: Screening for substance use, suicide, and safety in South African emergency departments
Victoria H Chen1, Bhakti Hansoti2, Aditi Rao3, Pamela Mda4, Henry Perry3, Thomas C Quinn5
1 Department of Public Health, Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA
2 Department of Emergency Medicine, Johns Hopkins University School of Medicine; Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
3 Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
4 Nelson Mandela Academic Clinical Research Unit, Walter Sisulu University, Mthatha, Eastern Cape, South Africa
5 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore; Division of Intramural Research, National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
|Date of Submission||17-Jul-2018|
|Date of Decision||09-Aug-2018|
|Date of Acceptance||26-Sep-2018|
|Date of Web Publication||24-Dec-2019|
Ms. Victoria H Chen
Krieger School of Arts and Sciences, Johns Hopkins University, 3400 N. Charles St., Baltimore 21218, MD
Source of Support: None, Conflict of Interest: None
Background: Emergency department (ED)-based screening for substance use, suicide, and safety is commonly conducted in the United States. We sought to adopt this ED-based strategy in South Africa to determine the potential unmet needs of this population.
Materials and Methods: This prospective, observational study was conducted at two sites in the Eastern Cape from June to September 2017. Adult patients presenting to the ED with noncritical conditions were approached to collect demographic data, respond to screening questions, and receive point-of-care human immunodeficiency virus testing. Screening questions assessed primary care access, substance use, suicidal thoughts, and home safety. The data analysis was performed using STATA v. 15 (StataCorp LLC, College Station, TX, USA). Descriptive statistics and cross-tabulations were performed to assess the proportion of patients with access to primary care, substance use, suicidal thoughts, and home safety. Relative risks were calculated using a generalized linear model for the appropriate exposures and outcomes.
Results: Among the 2,074 patients approached, 1,880 consented to data collection. Half of the participants were male, and the median age was 34 years (interquartile range: 25–54 years). Screening questions revealed that 384 (20%) used alcohol in excess, 372 (20%) used tobacco, 174 (9%) lacked access to primary care, 69 (4%) had suicidal thoughts, and 55 (3%) felt unsafe at home. Most of those reporting substance use were male and between 25 and 34 years.
Conclusions: One in five patients reported substance use, of which one in five did not have routine interaction with the health-care system. Routine ED-based screening could reach this missed population for timely intervention.
The following core competencies are addressed in this article: Patient care, Practice-based learning and improvement, and Systems-based practice.
Keywords: Emergency department, human immunodeficiency virus, screening, South Africa, substance use
|How to cite this article:|
Chen VH, Hansoti B, Rao A, Mda P, Perry H, Quinn TC. An opportunity for intervention: Screening for substance use, suicide, and safety in South African emergency departments. Int J Acad Med 2019;5:184-90
|How to cite this URL:|
Chen VH, Hansoti B, Rao A, Mda P, Perry H, Quinn TC. An opportunity for intervention: Screening for substance use, suicide, and safety in South African emergency departments. Int J Acad Med [serial online] 2019 [cited 2020 Nov 27];5:184-90. Available from: https://www.ijam-web.org/text.asp?2019/5/3/184/273930
| Introduction|| |
In many parts of the world, the emergency department (ED) is the safety net for the health-care system. EDs see high volumes of patients who present for care, which provide an ideal opportunity to identify various groups of vulnerable patients. Among these are individuals with mental or social problems that could be amenable to intervention––such as suicidality, alcoholism, drug addiction, and domestic abuse., Early identification of health-related issues in the ED can lead to prompt intervention and linkage to care.
In the United States, patients who come for care at EDs are routinely screened for human immunodeficiency virus (HIV), and those with opioid addiction and depression are identified and referred for follow-up care., However, in low- and middle-income countries, the ED is underutilized as a venue to identify patients in need of further ongoing care.
South Africa has a high prevalence of trauma, substance abuse, and HIV. Previous studies in South Africa show that 26%–36% of ED presentations are trauma related., Excessive alcohol use, estimated to affect 17% of males, has been associated with significant increases in injury and trauma., Since the national prevalence of HIV is in the range of 12.2%–30.8%,, the effects of not identifying high-risk behaviors and capturing unmet needs are magnified. Although there have been previous studies that document a high prevalence of substance abuse among patients seen in EDs in South Africa and their amenability to interventions, patient screening in the ED is not standard practice. The objective of this exploratory, prospective observational study is to identify opportunities for implementing screening programs in the ED.
| Materials and Methods|| |
This study was conducted from June 27 to September 3, 2017, at two EDs in Mthatha, the capital of the Eastern Cape Province of South Africa. The Nelson Mandela Academic Hospital is a provincial government-funded tertiary hospital that predominantly serves referred patients. Mthatha Regional Hospital is a nearby secondary health center that sees a high volume of walk-in patients. Together, the two facilities serve a 100-km radius catchment area and provide 24-h emergency care at their EDs. Patients often bring their own medical charts, and there is no electronic medical record system. Nurse-led triage and vital-sign collection are not a part of routine care.
Ten local research assistants were trained in HIV counseling and testing (HCT) and the research protocol. Adult patients (≥18 years) presenting to the ED with noncritical conditions assessed by the South African Triage Scale  were approached by research assistants to collect demographic data and receive point-of-care HIV testing and counseling. In addition to clinical and demographic data, all patients were asked five screening questions with Yes/No/Refused response options. The screening questions were used to identify patients with no primary care, those living in an unsafe home environment, those with suicidal thoughts, and those who had used tobacco or excessive alcohol in the previous 12 months. Patient responses were recorded on a case report form.
No primary care was elicited by asking, “Do you have access to primary care?” Access was defined as utilizing a community clinic. Unsafe home environment was elicited by asking, “Do you feel safe at home?” Home was defined as within the family or immediate community. Suicidal thoughts were elicited by asking, “Do you have thoughts of suicide?” Tobacco use was elicited by asking, “Do you smoke/take tobacco regularly?” Excessive alcohol use was elicited by asking, “Do you drink alcohol in excess regularly?” Regularity for both questions was defined as most days of the week.
Data from the two sites were pooled for analysis due to their similarity in demographic characteristics. Descriptive statistics and cross-tabulations were used to assess the proportion of patients with without access to primary care, with substance abuse, with suicidal thoughts, and with an unsafe home environment. The Pearson's Chi-squared test was used to compare the prevalence of patient-identified needs by age and gender. The data analysis was performed using STATA v. 15(StataCorp LLC, College Station, TX, USA).
To identify target populations for public health intervention, patients reporting substance use were characterized in terms of chief complaint for trauma. Patients presenting with trauma were further characterized by their mode of injury: assault, accidental, self-harm, or legal/military. HIV status was examined for correlation with screening responses. An HIV-positive status was further characterized in terms of whether the infection was already known to the patient or was a new diagnosis. A generalized linear model was used to calculate the relative risk (RR) for the appropriate exposures and outcomes.
This study received approval from the Institutional Review Board at the Johns Hopkins University, the Human Research Ethics Committee at the University of Cape Town and the Walter Sisulu University, the Eastern Cape Department of Health, and the administration at both study sites.
| Results|| |
During the study period, 4,255 patients presented to the ED across the two sites: 1,010 patients at Nelson Mandela Academic Hospital and 3,245 at Mthatha Regional Hospital [Table 1]. A total of 2,074 (48.7%) were approached by research assistants, of which 1,880 (90.6%) consented to participate in this study.
|Table 1: Distribution of demographic characteristics of emergency department patients at Mthatha Regional Hospital and Nelson Mandela Academic Hospital, South Africa|
Click here to view
[Table 1] contains the characteristics of the study population of 1,880 patients included in the study. The study sample was comprised 914 (48.6%) males and 966 (51.4%) females. The ages of the participants ranged from 18 to 98 years, with a median of 34 (interquartile range: 25–54) years. The median age was 32 years for males (interquartile range: 25–49) and 36 years for females (interquartile range: 25–57) [Table 1]. The age distribution of the study sample is presented in [Figure 1].
|Figure 1: Age and gender distribution of study participants (bar graph) with an overlay of percent of patients with no access to primary care (line graph)|
Click here to view
Among study participants, 512 (27.2%) were HIV positive, of whom 142 (7.6%) had a new diagnosis of HIV. One-third (601, 32.0%) of the study participants presented with a trauma complaint, more than half (343; 18.2%) of which were assault injuries.
Patient needs identified by the screening questions are shown in [Figure 2]. Screening for substance abuse in the previous 12 months revealed that 384 (20.4%) used alcohol in excess, 372 (19.8%) used tobacco, and 122 (12.2%) used both. The screening responses also revealed 174 (9.3%) lacked access to primary care, 69 (3.7%) had suicidal thoughts, and 55 (2.9%) felt unsafe at home. Access to primary care varied considerably by age and gender [Figure 1].
|Figure 2: Percent of patients with identified behaviors or conditions based on screening questions (n = 1880)|
Click here to view
Males were significantly more at risk than women for having no primary care (RR: 2.9 [2.1–4.1]) and substance use (RR: 10.4 [7.4–14.7], tobacco use; RR: 5.7 [4.4–7.4], excessive alcohol) but at significantly lower risk than women for having suicidal thoughts (RR: 0.6 [0.4–0.97]). There was no significant gender difference in feeling unsafe at home [Table 2].
|Table 2: Distribution of responses to screening questions and relative risks by demographic characteristics (n=1880)|
Click here to view
Patients aged 18–24 years had a significantly higher risk for having no primary care (RR: 2.5 [1.6–3.9]) and having suicidal thoughts (RR: 7.4 [2.6–20.9]) compared to the reference group of 55+ years. Patients aged 25–34 years had a significantly higher risk for substance use (RR: 3.1 [2.3–4.3], tobacco; RR: 2.6 [1.9–3.4], excessive alcohol) compared to the reference group of 55+ years. There was no significant age difference in feeling unsafe at home [Table 2].
Age and gender differences were found to be statistically significant for primary care access, suicidal thoughts, and substance use. Age and gender differences were not statistically significant for feeling unsafe at home.
Not having access to primary care is associated with an increased the risk of substance use (RR: 2.6 [2.0–3.5], tobacco; RR: 2.2 [1.7–3.0], excessive alcohol) but not for suicidal thoughts or feeling unsafe at home [Table 2]. Patients with a history of substance use were also more likely to present to the ED with a trauma complaint (RR: 2.5 [2.3–2.9], tobacco; RR: 2.5 [2.2–2.8], excessive alcohol) and from an assault injury in particular (RR: 3.8 [3.1–4.5], tobacco; RR: 3.4 [2.9–4.1], excessive alcohol) [Table 3].
|Table 3: Relative risks for trauma, assault injury, and suicidal thoughts by self-reported substance abuse status|
Click here to view
Compared with being HIV negative, having a known HIV diagnosis significantly decreased the risk of having no primary care (5.2%, RR: 0.2 [0.1–0.4]) and substance use (7.5%, RR: 0.5 [0.4–0.7], tobacco; 7.8%, RR: 0.6 [0.4–0.8], excessive alcohol). That is to say, those who were previously known to be HIV positive were more likely to have primary health care and less likely to use tobacco or excessive alcohol. The RRs of having no primary care and substance use were not significant for patients with a new HIV diagnosis. There were no significant HIV status differences in suicidal thoughts or feeling unsafe at home [Table 2].
| Discussion|| |
The purpose of this study was to inform improvements in the delivery of health-care services for ED patients in the Eastern Cape Province of South Africa. Our study findings identified benefits of implementing screening for substance use, suicide, and safety. The characteristics of ED-based care make it an ideal site for carrying out secondary prevention through patient screening. ED-based screening is particularly beneficial in addressing the unmet needs of young males who are otherwise disconnected from the primary care system. In South Africa, men are particularly reluctant to utilize primary care for HIV testing due to stigma, cultural practices, or prohibitive attitudes. Thus, an ED-based screening approach to HIV and other risk factors holds great potential for reaching people who are otherwise missed by the health-care system.
One in five patients presenting to the ED in the Eastern Cape Region of South Africa reported tobacco use or excessive alcohol use, and one in eight reported using both. The prevalence of suicidal thoughts and feeling unsafe at home among study participants was lower than previously reported national statistics in South Africa., Compared to males, females in our study were more likely to have suicidal thoughts and report feeling unsafe at home. This is in line with findings from other recent studies regarding the increased prevalence of suicidal ideation among females in South Africa.
Nearly 9.3% of study patients lacked access to primary care, but this rate varies considerably by age and gender. Screening questions revealed that males under 35 years are much more likely to lack access to primary care than other groups. Not having access to primary care was found to be significantly associated with the likelihood of substance use. This could be due to the predominance of implementing mental health interventions in primary care settings. Furthermore, substance abusers may face greater barriers to obtaining care due to financial limitations or social marginalization. Infrequent interaction with the health-care system reduces opportunities for preventive care. Thus, routine ED-based screening could reach this missed population for timely intervention.
About 19.8% of our ED population reported substance abuse, which is higher than the 13.4% lifetime prevalence of substance use reported nationally from household surveys in South Africa. Among substance users, one in five lacks access to primary care, indicating a missed opportunity for public health intervention. Substance abuse was also linked to increased risk for suicidal thoughts, having trauma complaints, and assault injuries. Although previous studies have linked excessive alcohol use to increased injury and trauma in South Africa,, this study also implicates tobacco use as a significant risk factor. Thus, utilizing routine ED-based screening to identify substance use and initiate timely intervention can be very beneficial to those who lack access to primary care.
Compared to those who are HIV negative or have a new HIV diagnosis, our study found that patients with a known HIV diagnosis are significantly more likely to have access to primary care and abstain from substance use. Whether this is due to increased patient education from more frequent interaction with the primary care system is unclear, presenting an area for further investigation. In South Africa, the integration of systematic HCT at primary care clinics in accordance with national guidelines has been effective in diagnosing and treating HIV., As a natural extension of the primary care network, our study shows that the ED is a suitable place to also screen for HIV, as well as substance use, suicide, and safety. Implementing screening programs in the ED would improve patient care for those who are not engaged with the primary health-care system in the Eastern Cape, South Africa.
Although the study protocol was to approach every adult patient presenting in the ED with noncritical conditions, the existing infrastructure and workflow of the facilities imposed several limitations. Patients presenting to or discharging from the ED were tracked infrequently by hospital staff on paper registers with duplications and missing entries. Multiple points of entry into and out of the ED made it difficult to account for every patient, and the registers included children and other patients who did not meet the inclusion criteria. The critical care volume was unknown since patients presenting with high severity were not documented. Thus, the counted total ED patient volume is a best approximation, and our study population may not be perfectly representative of the entire population of patients presenting to the ER with a noncritical complaint.
In Mthatha Regional Hospital, a secondary health facility, patients were first seen by a nurse who assigned them to either the ED or outpatient department during business hours. After business hours, all patients were directed to the ED regardless of complaint severity. Thus, not everyone presenting to the facility seeking urgent care entered the ED, where screening questions were administered. Maintaining confidentiality when administering the screening questions was challenging given the space limitations of the facilities. Due to self-reporting bias and stigma, screening questions may underestimate the prevalence of patient-identified needs, particularly for feeling unsafe at home and suicidal thoughts.
| Conclusions|| |
The findings from this study suggest that routine ED-based screening, particularly for substance use, should be implemented in the Eastern Cape region of South Africa to identify opportunities for timely public health intervention. Males are most likely to benefit from an ED-based screening policy because they report the highest rates of substance use and primary care underutilization. However, screening in females is important for identifying suicidal thoughts. Therefore, a routine and universal screening approach should be implemented. Further investigations are needed to determine the most effective approaches for linking patients with identified risk factors to appropriate care and follow-up.
The authors would like to thank Nomzamo Mvandaba and Kathryn Clark for their role in research coordination and data validation. The authors would also like to thank the HIV Counselling and Testing team, as well as the staff at Nelson Mandela Academic Hospital and Mthatha Regional Hospital for making this research possible.
Financial support and sponsorship
This research was supported by the Johns Hopkins Center for Global Health, the Johns Hopkins Woodrow Wilson Research Fellowship, the South African Medical Research Council, and the Division of Intramural Research, the National Institute of Allergy and Infectious Diseases, National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
Prior to data collection, this study received approval from the Institutional Review Board at the Johns Hopkins University, the Human Research Ethics Committee at the University of Cape Town and the Walter Sisulu University, the Eastern Cape Department of Health, and the administration at both study sites. All study participants were consenting adults in noncritical condition. Appropriate EQUATOR Network (http://www.equator-network.org) research reporting guidelines were followed.
| References|| |
Allen MH, Abar BW, McCormick M, Barnes DH, Haukoos J, Garmel GM, et al.
Screening for suicidal ideation and attempts among emergency department medical patients: Instrument and results from the psychiatric emergency research collaboration. Suicide Life Threat Behav 2013;43:313-23.
Monti PM, Mastroleo NR, Barnett NP, Colby SM, Kahler CW, Operario D, et al.
Brief motivational intervention to reduce alcohol and HIV/sexual risk behavior in emergency department patients: A randomized controlled trial. J Consult Clin Psychol 2016;84:580-91.
Rothman RE, Hsieh YH, Harvey L, Connell S, Lindsell CJ, Haukoos J, et al
. 2009 US emergency department HIV testing practices. Ann Emerg Med 2011;58:S3-9.e1-4.
D'Onofrio G, O'Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, et al.
Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA 2015;313:1636-44.
Babeva K, Hughes JL, Asarnow J. Emergency department screening for suicide and mental health risk. Curr Psychiatry Rep 2016;18:100.
Hanewinckel R, Jongman HP, Wallis LA, Mulligan TM. Emergency medicine in Paarl, South Africa: A cross-sectional descriptive study. Int J Emerg Med 2010;3:143-50.
Hodkinson PW, Wallis LA. Cross-sectional survey of patients presenting to a South African urban emergency centre. Emerg Med J 2009;26:635-40.
Peltzer K, Davids A, Njuho P. Alcohol use and problem drinking in South Africa: Findings from a national population-based survey. Afr J Psychiatry (Johannesbg) 2011;14:30-7.
Plüddemann A, Parry C, Donson H, Sukhai A. Alcohol use and Trauma in Cape Town, Durban and port Elizabeth, South Africa: 1999--2001. Inj Control Saf Promot 2004;11:265-7.
Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Zungu N, et al.
South African National HIV prevalence, incidence and behaviour survey, 2012. Cape Town, South Africa: HSRC Press 2014. Available from: http://www.hsrc.ac.za/en/research-data/view/6871
. [Last accessed on 2018 Apr 15].
Schlebusch L, Vawda N. HIV-infection as a self-reported risk factor for attempted suicide in South Africa. Afr J Psychiatry (Johannesbg) 2010;13:280-3.
Sorsdahl K, Stein DJ, Corrigall J, Cuijpers P, Smits N, Naledi T, et al.
The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial. Subst Abuse Treat Prev Policy 2015;10:46.
Twomey M, Wallis LA, Thompson ML, Myers JE. The South African triage scale (adult version) provides reliable acuity ratings. Int Emerg Nurs 2012;20:142-50.
Mambanga P, Sirwali RN, Tshitangano T. Factors contributing to men's reluctance to seek HIV counselling and testing at primary health care facilities in Vhembe district of South Africa. Afr J Prim Health Care Fam Med 2016;8:e1-7.
Khasakhala L, Sorsdahl KR, Harder VS, Williams DR, Stein DJ, Ndetei DM, et al.
Lifetime mental disorders and suicidal behaviour in South Africa. Afr J Psychiatry (Johannesbg) 2011;14:134-9.
Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic violence: Findings from a South African cross-sectional study. Soc Sci Med 2002;55:1603-17.
Stein DJ, Seedat S, Herman A, Moomal H, Heeringa SG, Kessler RC, et al.
Lifetime prevalence of psychiatric disorders in South Africa. Br J Psychiatry 2008;192:112-7.
Petersen I, Ssebunnya J, Bhana A, Baillie K, MhaPP Research Programme Consortium. Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda. Int J Ment Health Syst 2011;5:8.
Uebel KE, Lombard C, Joubert G, Fairall LR, Bachmann MO, Mollentze WF, et al.
Integration of HIV care into primary care in South Africa: Effect on survival of patients needing antiretroviral treatment. J Acquir Immune Defic Syndr 2013;63:e94-100.
Van Rie A, Clouse K, Hanrahan C, Selibas K, Sanne I, Williams S, et al.
High uptake of systematic HIV counseling and testing and TB symptom screening at a primary care clinic in South Africa. PLoS One 2014;9:e105428.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]