Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda.

BACKGROUND: Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies. METHODS: Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus. RESULTS: Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05). CONCLUSIONS: Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.

Caregivers' Experiences of Pathways to Care for Seriously Ill Children in Cape Town, South Africa: A Qualitative Investigation.

PURPOSE: Understanding caregivers' experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers' experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement. METHODS: Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers' experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison. RESULTS: Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed 'tactics' to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism. CONCLUSIONS: Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers' use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.

Qualitative exploration of the career aspirations of rural origin health science students in South Africa.

INTRODUCTION: There is evidence in the literature that rural background significantly encourages eventual rural practice. Given the shortage of healthcare providers in rural areas, we need to explore ways of ensuring throughput and success of rural-origin students in health sciences. It is therefore important to understand who these students are, what motivates them and the factors involved in the formation of their career choices. METHODS: The aim of this study is to understand the aspirations of undergraduate health science students of rural origin with regard to their future career plans. The objectives of the study include to explore and identify the key issues facing rural-origin students with regard to their future career plans. Individual interviews were conducted with 15 health science students from two South African universities. Transcriptions were analyzed with the aid of Nvivo v8 (www.qsrinternational.com). RESULTS: The findings suggest health science students of rural origin studying at universities in the South African context face specific challenges related to the nature of the contrast between rural and urban life, in addition to the more generic adaptations that confront all students on entering tertiary education. CONCLUSION: In order to support rural students in their studies, academic, financial, emotional and social stressors need to be addressed. Universities should strengthen existing support structures as well as aid the development of further support that may be required.Key words: career plan, health science, rural background, South Africa.

Perspectives on key principles of generalist medical practice in public service in sub-Saharan Africa: a qualitative study.

BACKGROUND: The principles and practice of Family Medicine that arose in developed Western countries have been imported and adopted in African countries without adequate consideration of their relevance and appropriateness to the African context. In this study we attempted to elicit a priori principles of generalist medical practice from the experience of long-serving medical officers in a variety of African counties, through which we explored emergent principles of Family Medicine in our own context. METHODS: A descriptive study design was utilized, using qualitative methods. 16 respondents who were clinically active medical practitioners, working as generalists in the public services or non-profit sector for at least 5 years, and who had had no previous formal training or involvement in academic Family Medicine, were purposively selected in 8 different countries in southern, western and east Africa, and interviewed. RESULTS: The respondents highlighted a number of key issues with respect to the external environment within which they work, their collective roles, activities and behaviours, as well as the personal values and beliefs that motivate their behaviour. The context is characterized by resource constraints, high workload, traditional health beliefs, and the difficulty of referring patients to the next level of care. Generalist clinicians in sub-Saharan Africa need to be competent across a wide range of clinical disciplines and procedural skills at the level of the district hospital and clinic, in both chronic and emergency care. They need to understand the patient's perspective and context, empowering the patient and building an effective doctor-patient relationship. They are also managers, focused on coordinating and improving the quality of clinical care through teamwork, training and mentoring other health workers in the generalist setting, while being life-long learners themselves. However, their role in the community, was found to be more aspirational than real. CONCLUSIONS: The study derived a set of principles for the practice of generalist doctors in sub-Saharan Africa based on the reported activities and approaches of the respondents. Patient-centred care using a biopsychosocial approach remains as a common core principle despite wide variations in context. Procedural and hospital care demands a higher level of skills particularly in rural areas, and a community orientation is desirable, but not widely practiced. The results have implications for the postgraduate training of family physicians in sub-Saharan Africa, and highlight questions regarding the realization of community-orientated primary care.

Pedagogy for rural health.

CONTEXT: As the body of literature on rural health has grown, the need to develop a unifying theoretical framework has become more apparent. There are many different ways of seeing the same phenomenon, depending on the assumptions we make and the perspective we choose. A conceptual and theoretical basis for the education of health professionals in rural health has not yet been described. APPROACH: This paper examines a number of theoretical frameworks that have been used in the rural health discourse and aims to identify relevant theory that originates from an educational paradigm. The experience of students in rural health is described phenomenologically in terms of two complementary perspectives, using a geographic basis on the one hand, and a developmental viewpoint on the other. The educational features and implications of these perspectives are drawn out. DISCUSSION: The concept of a 'pedagogy of place' recognizes the importance of the context of learning and allows the uniqueness of a local community to integrate learning at all levels. The theory of critical pedagogy is also found relevant to education for rural health, which would ideally produce 'transformative' graduates who understand the privilege of their position, and who are capable of and committed to engaging in the struggles for equity and justice, both within their practices as well as in the wider society. CONCLUSION: It is proposed that a 'critical pedagogy of place,' which gives due acknowledgement to local peculiarities and strengths, while situating this within a wider framework of the political, social and economic disparities that impact on the health of rural people, is an appropriate theoretical basis for a distinct rural pedagogy in the health sciences.