Julia Blitz

What keeps health professionals working in rural district hospitals in South Africa

Background The theme of the 2014 Southern African Rural Health Conference was ‘Building resilience in facing rural realities’. Retaining health professionals in South Africa is critical for sustainable health services. Only 12% of doctors and 19% of nurses have been retained in the rural areas. The aim of the workshop was to understand from health practitioners why they continued working in their rural settings. Conference workshop The workshop consisted of 29 doctors, managers, academic family physicians, nurses and clinical associates from Southern Africa, with work experience from three weeks to 13 years, often in deep rural districts. Using the nominal group technique, the following question was explored, ‘What is it that keeps you going to work every day?’ Participants reflected on their work situation and listed and rated the important reasons for continuing to work. Results Five main themes emerged. A shared purpose, emanating from a deep sense of meaning, was the strongest reason for staying and working in a rural setting. Working in a team was second most important, with teamwork being related to attitudes and relationships, support from visiting specialists and opportunities to implement individual clinical skills. A culture of support was third, followed by opportunities for growth and continuing professional development, including teaching by outreaching specialists. The fifth theme was a healthy work-life balance. Conclusion Health practitioners continue to work in rural settings for often deeper reasons relating to a sense of meaning, being part of a team that closely relate to each other and feeling supported.

Modifiable antenatal risk factors for stillbirth amongst pregnant women in the Omusati region, Namibia.

Background Reduction of stillbirth rates is important because of the social and economic implications. Access to quality antenatal care is important in preventing the risk factors associated with stillbirth. Aim To determine the prevalence of modifiable antenatal risk factors associated with stillbirth so as to determine possible gaps in their prevention. Setting The study was conducted at four district hospitals in the Omusati Region of Namibia. Methods A descriptive study using recorded antenatal data was used. Data were collected from the records of 82 women at the time that they had a stillbirth, during the period October 2013 to December 2014. Data were collected for modifiable risk factors related to maternal characteristics, antenatal care received, medical conditions and obstetric complications. Results The average prevalence of each category of risk factors was as follows: quality of antenatal care (19.8%), maternal characteristics (11.4%), medical conditions (8.9%) and obstetric complications (6.5%). The most prevalent individual risk factors included: no folate supplementation (30.5%), HIV infection (25.6%), late booking (16.7%), intrauterine foetal growth retardation (13.4%) and alcohol use (12.5%). Conclusion Amongst the 14 modifiable risk factor included in the present study, 11 (78.6%) were prevalent amongst women who had a stillbirth. Risk factors associated with quality of antenatal care were the most prevalent. Whilst further investigation is needed to determine the causes behind this prevalence, health education on the availability and benefits of antenatal care, pregnancy timing and spacing may contribute to reducing the prevalence of these risk factors.

Perceptions of doctors and nurses at a Ugandan hospital regarding the introduction and use of the South African Triage Scale

Background International Hospital Kampala (IHK) experienced a challenge with how to standardise the triaging and sorting of patients. There was no triage tool to help to prioritise which patients to attend to first, with very sick patient often being missed. Aim and setting To explore whether the introduction of the South African Triage Scale (SATS) was seen as valuable and sustainable by the IHK’s outpatient department and emergency unit (OPD and EU) staff. Methods The study used qualitative methods to introduce SATS in the OPD and EU at IHK and to obtain the perceptions of doctors and nurses who had used it for 3–6 months on its applicability and sustainability. Specific questions about challenges faced prior to its introduction, strengths and weaknesses of the triage tool, the impact it had on staff practices, and their recommendations on the continued use of the tool were asked. In-depth interviews were conducted with 4 doctors and 12 nurses. Results SATS was found to be necessary, applicable and recommended for use in the IHK setting. It improved the sorting of patients, as well as nurse-patient and nurse-doctor communication. The IHK OPD & EU staff attained new skills, with nurses becoming more involved in-patient care. It is possibly also useful in telephone triaging and planning of hospital staffing. Conclusion Adequate nurse staffing, a computer application for automated coding of patients, and regular training would encourage consistent use and sustainability of SATS. Setting up a hospital committee to review signs and symptoms would increase acceptability and sustainability. SATS is valuable in the IHK setting because it improved overall efficiency of triaging and care, with significantly more strengths than weaknesses.

Overcoming challenges in primary care education in South Africa

South Africa achieved democracy in 1994 and for the first time committed itself to make primary healthcare the cornerstone of the health system for the whole population. The new government inherited a health system that was fragmented along racial and geographical lines, had inadequate infrastructure and was deeply inequitable. The incoming president immediately announced that primary healthcare would be free for mothers, children and indigent people, which increased demand on an already fragile and poorly functioning system. In this situation the only cadre of health workers large enough was nurses and therefore the primary care system became nurse-driven. Today 80% of all consultations in primary care are with nurses.1 In addition the health sector was challenged to find ways to deal with the rapidly growing epidemic of HIV and TB in the face of the government’s HIV denialism and initial failure to provide anti-retroviral treatment. The burden of disease from HIV and TB remains disproportionately higher than the other three significant burdens of interpersonal violence and trauma, poor maternal and child health and emerging non-communicable chronic diseases.2 Currently South Africa has only 3.7 medical practitioners and 2.0 specialists per 10 000 people.3 These are also inequitably distributed with a preponderance being in the private (medical insurance-funded) sector as well as in urban areas. It should be noted that in the South African public sector generalist care by doctors includes service at district hospitals, often in rural and remote locations, as well as in primary care.4 Over the last 20 years much progress has been made in establishing a district health system with clear boundaries and management structures as well as renovating existing and building new infrastructure. In the last few years the government has developed a long-term vision of universal coverage through national health insurance.5 This policy requires that the quality of public sector services be improved so that they would be acceptable to the whole population and that a large portion of the resources currently spent in the private sector (60% of all expenditure on healthcare for 16% of the population) be integrated into the health system for everyone. The human resources for primary healthcare are obviously a critical ingredient in achieving this vision. Many different health professionals are involved in delivering primary healthcare, but for the purposes of this article we will focus on the primary care education of four key groups: doctors, nurses, community health workers and clinical associates.

PIQUE-ing an interest in curriculum renewal : research

Background. The primary aim of undergraduate medical training at South African medical schools is to prepare the graduates adequately for internship. If we are to attain this objective, it is crucial to evaluate the ability of our graduates to cope with the demands of internship. Objective. To determine the extent to which first-year interns from Stellenbosch University (SU) considered that their undergraduate education prepared them for internship. Methods. The Preparedness for Internship Questionnaire (PIQUE) is based on Hill’s Preparation for Hospital Practice Questionnaire, with additional questions covering core competencies and exit outcomes that SU has determined for its medical curriculum. Participants were asked to respond to a series of statements preceded by ‘My undergraduate medical training prepared me to … ’, and also two open-ended questions. SU’s MB ChB graduates of 2011 ( N =153) were invited to participate in the online survey . Results. Although the response rate was only 37%, graduates generally thought they had been well prepared for most mainstream clinical activities. However, there were areas in which respondents considered they could have been better prepared, specifically pharmacology, medicolegal work, minor surgery and the non-clinical roles that interns encounter. Conclusion. PIQUE appears to be a useful tool that can assist with curriculum renewal by highlighting areas that graduates feel they could be better prepared for. This challenges us to identify how curricula and teaching can be adjusted accordingly.

Emergency contraceptive knowledge, attitudes and practices among female students at the University of Botswana: A descriptive survey

Background Unintended pregnancies are associated with unsafe abortions and maternal deaths, particularly in countries such as Botswana, where abortion is illegal. Many of these unwanted pregnancies could be avoided by using emergency contraception, which is widely available in Botswana. Aim To assess the level of knowledge, attitudes and practices of female students with regard to emergency contraception at the University of Botswana. Setting Students from University of Botswana, Gaborone, Botswana. Methods A descriptive survey among 371 students selected from all eight faculties at the university. Data were collected using a self-administered questionnaire and analysed using the Statistical Package for Social Sciences. Results The mean age was 20.6 years (SD 1.62), 58% were sexually active, 22% had used emergency contraception and 52% of pregnancies were unintended. Of the total respondents, 95% replied that they had heard of emergency contraception; however, only 53% were considered to have good knowledge, and 55% had negative attitudes towards its use. Students from urban areas had better knowledge than their rural counterparts (p = 0.020). Better knowledge of emergency contraception was associated with more positive attitudes towards actual use (p < 0.001). Older students (p < 0.001) and those in higher years of study (p = 0.001) were more likely to have used emergency contraception. Conclusion Although awareness of emergency contraception was high, level of knowledge and intention to use were low. There is a need for a targeted health education programme to provide accurate information about emergency contraception.

Training of workplace-based clinical trainers in family medicine, South Africa: Before-and-after evaluation

Background The training of family physicians is a relatively new phenomenon in the district health services of South Africa. There are concerns about the quality of clinical training and the low pass rate in the national examination. Aim To assess the effect of a five-day course to train clinical trainers in family medicine on the participants’ subsequent capability in the workplace. Setting Family physician clinical trainers from training programmes mainly in South Africa, but also from Ghana, Uganda, Kenya, Malawi and Botswana. Methods A before-and-after study using self-reported change at 6 weeks (N = 18) and a 360-degree evaluation of clinical trainers by trainees after 3 months (N = 33). Quantitative data were analysed using the Statistical Package for Social Sciences, and qualitative data were analysed thematically. Results Significant change (p < 0.05) was found at 6 weeks in terms of ensuring safe and effective patient care through training, establishing and maintaining an environment for learning, teaching and facilitating learning, enhancing learning through assessment, and supporting and monitoring educational progress. Family physicians reported that they were better at giving feedback, more aware of different learning styles, more facilitative and less authoritarian in their educational approach, more reflective and critical of their educational capabilities and more aware of principles in assessment. Despite this, the trainees did not report any noticeable change in the trainers’ capability after 3 months. Conclusion The results support a short-term improvement in the capability of clinical trainers following the course. This change needs to be supported by ongoing formative assessment and supportive visits, which are reported on elsewhere.

Decentralised training for medical students: a scoping review

BackgroundIncreasingly, medical students are trained at sites away from the tertiary academic health centre. A growing body of literature identifies the benefits of decentralised clinical training for students, the health services and the community. A scoping review was done to identify approaches to decentralised training, how these have been implemented and what the outcomes of these approaches have been in an effort to provide a knowledge base towards developing a model for decentralised training for undergraduate medical students in lower and middle-income countries (LMICs).MethodsUsing a comprehensive search strategy, the following databases were searched, namely EBSCO Host, ERIC, HRH Global Resources, Index Medicus, MEDLINE and WHO Repository, generating 3383 references. The review team identified 288 key additional records from other sources. Using prespecified eligibility criteria, the publications were screened through several rounds. Variables for the data-charting process were developed, and the data were entered into a custom-made online Smartsheet database. The data were analysed qualitatively and quantitatively.ResultsOne hundred and five articles were included. Terminology most commonly used to describe decentralised training included ‘rural’, ‘community based’ and ‘longitudinal rural’. The publications largely originated from Australia, the United States of America (USA), Canada and South Africa. Fifty-five percent described decentralised training rotations for periods of more than six months. Thematic analysis of the literature on practice in decentralised medical training identified four themes, each with a number of subthemes. These themes were student learning, the training environment, the role of the community, and leadership and governance.ConclusionsEvident from our findings are the multiplicity and interconnectedness of factors that characterise approaches to decentralised training. The student experience is nested within a particular context that is framed by the leadership and governance that direct it, and the site and the community in which the training is happening. Each decentralised site is seen to have its own dynamic that may foreground certain elements, responding differently to enabling student learning and influencing the student experience. The insights that have been established through this review have relevance in informing the further expansion of decentralised clinical training, including in LMIC contexts.

Decentralised training for medical students: Towards a South African consensus

Introduction Health professions training institutions are challenged to produce greater numbers of graduates who are more relevantly trained to provide quality healthcare. Decentralised training offers opportunities to address these quantity, quality and relevance factors. We wanted to draw together existing expertise in decentralised training for the benefit of all health professionals to develop a model for decentralised training for health professions students. Method An expert panel workshop was held in October 2015 initiating a process to develop a model for decentralised training in South Africa. Presentations on the status quo in decentralised training at all nine medical schools in South Africa were made and 33 delegates engaged in discussing potential models for decentralised training. Results Five factors were found to be crucial for the success of decentralised training, namely the availability of information and communication technology, longitudinal continuous rotations, a focus on primary care, the alignment of medical schools’ mission with decentralised training and responsiveness to student needs. Conclusion The workshop concluded that training institutions should continue to work together towards formulating decentralised training models and that the involvement of all health professions should be ensured. A tripartite approach between the universities, the Department of Health and the relevant local communities is important in decentralised training. Lastly, curricula should place more emphasis on how students learn rather than how they are taught.