Exploring doctors' trade-offs between management, research and clinical training in the medical curriculum: a protocol for a discrete choice experiment in Southern Africa.

INTRODUCTION: Medical curricula should prepare doctors for roles that extend beyond that of a clinician. But the formal inclusion of both management and research training still appear to be neglected. It is important to understand what the profession would be willing to give up in terms of clinical training time for management and research content teaching prior to making any changes in a medical curriculum. METHODS AND ANALYSIS: A discrete choice experiment will elicit the preferences and trade-offs that medical doctors in Southern Africa are prepared to make about the management, research and clinical training. Attention will also be given to the teaching method and placement of the content. DCE data will be collected using an online survey with an estimated sample size of 368 medical doctors. Data regarding participants' preference for a traditional or revised curriculum will be assessed using the Resistance to Change-Beliefs (RC-B) scale and demographic information will also be collected to assess preference heterogeneity.Analysis of the DCE data will be based on the Random Utility Maximisation framework using variants of the multinomial logit model. Data quality will be assessed. Value will be estimated in terms of clinical time, that is, how much clinical training time medical doctors are willing to give up to have research and management training within a curriculum that has a maximum of 40 hours per week. Observed preference heterogeneity will be assessed using the RC-B scale data and characteristics of respondents. Latent class models will be used to test for unobserved heterogeneity. ETHICS AND DISSEMINATION: The research ethics and institutional committees of the sites have approved the study. The survey includes an informed consent section. Study findings will be reported to the medical schools and papers will be submitted to peer-reviewed, accredited journals and higher education and health economic conferences.

Mapping evidence on cryptococcal antigen infection among HIV-infected persons in sub-Saharan Africa- A scoping review protocol.

INTRODUCTION: Infections of the central nervous system are a considerable basis of mortality in people living with HIV, with progression to cryptococcal meningitis documented at around 15% of HIV-associated mortality globally, with nearly three-quarters occurring in the sub-Saharan Africa. Discoveries from previous studies prelude to the mortality of cryptococcal antigen positive, which persisted to be elevated than in cryptococcal antigen negative persons. One feasible interpretation of this could be due to undiagnosed cryptococcus. Laboratory investigations identify cryptococcal disease prior to cryptococcal meningitis progression. Point-of-care testing has high sensitivity and specificity as seen with the cryptococcal antigen lateral flow assay screening to expedite treatment. The aim of the study is to map and translate evidence on cryptococcal antigen infection among HIV-infected persons in sub-Saharan Africa. METHODOLOGY: The proposed scoping review will be conducted using guidelines proposed by Arksey and O'Malley methodological framework and Levac et al. advanced method. It will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews. A comprehensive literature search of studies published from the first relevant publication to 2022 will be conducted on multiple electronic databases. Additional sources (grey literature) will also be searched. The search strategy will be generated and implemented by the principal investigator with assistance from a subject specialist, and an information specialist. Two reviewers will screen eligible studies. The screening will be guided by an inclusion and exclusion criteria. The mixed methods appraisal tool version 2018 will be used to appraise the quality of the empirical studies. DISCUSSION: The proposed scoping review will map and translate evidence on cryptococcal antigen infection among HIV-infected persons in sub-Saharan Africa. Synthesising and sharing recent evidence in this area has potential to help guide future research and interventions aimed at improving the management of cryptococcal antigen infection among HIV-infected persons in sub-Saharan Africa and other high HIV- burdened settings.

Undergraduate research- a tale of three African institutions.

Background: The inclusion of research in undergraduate medical curricula benefits students as well as the scientific community. Multiple studies report the presence of one or more barriers to research training in these curricula. Objectives: This paper presents and compares three studies done regarding the teaching of research in undergraduate medical curricula in South Africa, Sudan and Uganda. Methods: Two cross-sectional study designs (South Africa and Sudan) and one interventional study design (Uganda) were conducted. Both cross-sectional studies used mixed methods while the Ugandan study used a quantitative method. A total of 41 faculty members and 554 students participated. The studies used a combination of surveys, focus group discussions, key informant interviews and document analysis. Results: Participants from all three studies valued research and considered it useful and relevant to their studies. The findings from the South African and Sudanese studies align with the 'Four I's' framework that summarise the barriers to research training as lack of initiative, impulse, incentive and idols. The Ugandan study demonstrated improved self-reported knowledge and attitude (specifically anxiety) among participants after completion of a short course on research.

We know but we hope: A qualitative study of the opinions and experiences on the inclusion of management, health economics and research in the medical curriculum.

The achievement of global and national health goals requires a health workforce that is sufficient and trained. Despite considerable steps in medical education, the teaching of management, health economics and research skills for medical doctors are often neglected in medical curricula. This study explored the opinions and experiences of medical doctors and academic educationalists on the inclusion of management, health economics and research in the medical curriculum. A qualitative study was undertaken at four medical schools in Southern Africa (February to April 2021). The study population was medical doctors and academic educationalists. Semi-structured interviews with purposively sampled participants were conducted. All interviews were recorded and professionally transcribed. Constructivist grounded theory guided the analysis with the use of ATLAS.ti version 9.1.7.0 software. In total, 21 academic educationalists and 28 medical doctors were interviewed. In the first theme We know, participants acknowledged the constraints of medical schools but were adamant that management needed to be taught intentionally and explicitly. The teaching and assessment of management and health economics was generally reported to be ad hoc and unstructured. There was a desire that graduates are able to use, but not necessarily do research. In comparison to management and research, support for the inclusion of health economics in the curriculum was insignificant. Under We hope, educationalists hoped that the formal clinical teaching will somehow instil values and best practices of management and that medical doctors would become health advocates. Most participants wished that research training could be optimised, especially in relation to the duration of allocated time; the timing in the curriculum and the learning outcomes. Despite acknowledgement that management and research are topics that need to be taught, educationalists appeared to rely on chance to teach and assess management in particular. These qualitative study findings will be used to develop a discrete choice experiment to inform optimal curricula design.

Effect of a brief motivational interview and text message intervention targeting tobacco smoking, alcohol use and medication adherence to improve tuberculosis treatment outcomes in adult patients with tuberculosis: a multicentre, randomised controlled trial of the ProLife programme in South Africa.

OBJECTIVE: To investigate the effectiveness of a complex behavioural intervention, ProLife, on tuberculosis (TB) treatment success, medication adherence, alcohol use and tobacco smoking. DESIGN: Multicentre, individual, randomised controlled trial where participants were assigned (1:1) to the ProLife intervention or usual care. SETTING: 27 primary care clinics in South Africa. PARTICIPANTS: 574 adults starting treatment for drug-sensitive pulmonary TB who smoked tobacco or reported harmful/hazardous alcohol use. INTERVENTIONS: The intervention, delivered by lay health workers (LHWs), consisted of three brief motivational interviewing (MI) sessions, augmented with short message service (SMS) messages, targeting medication adherence, alcohol use and tobacco smoking. OUTCOME MEASURES: The primary outcome was successful versus unsuccessful TB treatment at 6-9 months, from TB records. Secondary outcomes were biochemically confirmed sustained smoking cessation, reduction in the Alcohol Use Disorder Identification Test (AUDIT) score, improved TB and antiretroviral therapy (ART) adherence and ART initiation, each measured at 3 and 6 months by questionnaires; and cure rates in patients who had bacteriology-confirmed TB at baseline, from TB records. RESULTS: Between 15 November 2018 and 31 August 2019, 574 participants were randomised to receive either the intervention (n=283) or usual care (n=291). TB treatment success rates did not differ significantly between intervention (67.8%) and control (70.1%; OR 0.9, 95% CI 0.64% to 1.27%). There was no evidence of an effect at 3 and 6 months, respectively, on continuous smoking abstinence (OR 0.65, 95% CI 0.37 to 1.14; OR 0.76, 95% CI 0.35 to 1.63), TB medication adherence (OR 1.22, 95% CI 0.52 to 2.87; OR 0.89, 95% CI 0.26 to 3.07), taking ART (OR 0.79, 95% CI 0.38 to 1.65; OR 2.05, 95% CI 0.80 to 5.27) or AUDIT scores (mean score difference 0.55, 95% CI -1.01 to 2.11; -0.04, 95% CI -2.0 to 1.91) and adjusting for baseline values. Cure rates were not significantly higher (OR 1.16, 95% CI 0.83 to 1.63). CONCLUSIONS: Simultaneous targeting of multiple health risk behaviours with MI and SMS using LHWs may not be an effective approach to improve TB outcomes. TRIAL REGISTRATION NUMBER: ISRCTN62728852.

Successful antibiotic stewardship in hospitalised children in a developing nation.

OBJECTIVES: Increasing antimicrobial resistance has become a looming threat to paediatric health and, therefore, health facilities are obliged to practice antimicrobial stewardship. This study was undertaken to review stewardship adherence in the Department of Pediatrics at the Central Hospital, Pretoria, South Africa. METHODS: Antibiotic prescriptions of children admitted to hospital were reviewed for consistency with the national essential medicines list from January 2017 to January 2019. Medical records of children were reviewed to obtain the primary diagnosis, requested laboratory investigations and antibiotic prescription practices. The management was adjudicated as consistent with policy by a score system. RESULTS: This study reveals that management was in agreement with standard guidelines in 69.3% of cases, with a range of 33-77%. From the start of the study in January 2017 to the final date in January 2019 there was a significant increase in the number of patients with respiratory tract infections who were treated correctly, increasing from 41% to 73% at study end. CONCLUSIONS: This study is the first to report the success of antibiotic stewardship in children admitted to a tertiary hospital in South Africa. However, it is critical that antibiotic stewardship be continued and antibiotic prescriptions be aligned with guidelines.

Final-year medical students need to know their future supervisory role of clinical associates.

BACKGROUND: A clinical associate (ClinA) is a mid-level health professional who may only practise under the supervision of a medical doctor. By extension, medical students need to be prepared for this responsibility. This study explored whether final-year medical students at one university were aware of this supervisory role, felt prepared and were knowledgeable about the ClinAs' scope of practice. METHODS: A descriptive, cross-sectional study was conducted. The population included all final-year medical students who had completed their District Health and Community Obstetrics rotations (March to November 2017). After an end-of-rotation session, 151 students were given questionnaires to complete. A list of 20 treatments or procedures was extracted from the ClinAs' gazetted scope of practice for a 'knowledge test'. Data were analysed with Stata and Microsoft Excel. Ethical permission was granted. RESULTS: The response rate was 77.4% (n/N = 117/151). The majority of participants (76.1%, n = 86) had worked with a qualified or student ClinA before and had a generally positive impression (81.4%; n = 70). Almost half (47.8%; n = 56) thought that the ClinAs' scope of work was similar to registered nurses rather than a doctor's (38.2%; n = 44). Most were unaware that they would be required to supervise ClinAs once qualified (65.8%; n = 77). On average, participants identified 12 out of 20 treatments or procedures that a ClinA could perform. CONCLUSION: Despite having worked with ClinAs, participants appeared largely unaware of their future legal obligation of supervision. Adequate clinical supervision is based on the knowledge of the scope of practice, which was variable. Formal training on the scope of the work of ClinAs is needed to prepare future doctors for their supervisory role. Medical schools have an obligation to adequately prepare their students in this regard as part of their transformative education with elements of interprofessional education.

ImPROving TB outcomes by modifying LIFE-style behaviours through a brief motivational intervention followed by short text messages (ProLife): study protocol for a randomised controlled trial.

BACKGROUND: South Africa is among the seven highest tuberculosis (TB) burden countries. Harmful lifestyle behaviours, such as smoking and alcohol, and poor adherence to medication can affect clinical outcomes. Modification of these behaviours is likely to improve TB treatment outcomes and has proven possible using motivational interviewing (MI) techniques or use of short message service (SMS) text messaging. There have been no studies assessing the effect of combined MI and SMS interventions on multiple lifestyle factors and TB treatment outcomes. METHODS: This is a prospective, multicentre, two-arm individual randomised controlled trial looking at the effectiveness and cost-effectiveness of a complex behavioural intervention (the ProLife programme) on improving TB and lifestyle-related outcomes in three provinces of South Africa. The ProLife programme consists of an MI counselling strategy, delivered by lay health workers, augmented with subsequent SMS. We aim to recruit 696 adult participants (aged 18 years and over) with drug-sensitive pulmonary TB who are current smokers and/or report harmful or hazardous alcohol use. Patients will be consecutively enrolled at 27 clinics in three different health districts in South Africa. Participants randomised individually to the intervention arm will receive three MI counselling sessions one month apart. Each MI session will be followed by twice-weekly SMS messages targeting treatment adherence, alcohol use and tobacco smoking, as appropriate. We will assess the effect on TB treatment success, using standard World Health Organization (WHO) treatment outcome definitions (primary outcome), as well as on a range of secondary outcomes including smoking cessation, reduction in alcohol use, and TB medication and anti-retroviral therapy adherence. Secondary outcomes will be measured at the three-month and six-month follow-ups. DISCUSSION: This trial aligns with the WHO agenda of integrating TB care with the care for chronic diseases of lifestyle, such as provision of smoking cessation treatments, and with the use of digital technologies. If the ProLife programme is found to be effective and cost-effective, the programme could have significant implications for TB treatment globally and could be successfully implemented in a wide range of TB treatment settings. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN62728852. Registered on 13 April 2018.

A case study of the use of a special interest group to enhance interest in public health among undergraduate health science students.

BACKGROUND: Education and training of undergraduate health science students in public health are insufficient in many parts of the world. This lack is a risk as early interest in specialist training options is a predictor of future training choices. A special interest group (SIG) is one mechanism to engage students, increase awareness and generate interest in public health. The purpose of this case study was to create and study such a group at an African university. CASE PRESENTATION: An action research study design was used to create and study the SIG. All interested students were invited to participate in the SIG and in the data collection procedures. Data were collected via paper-based and online questionnaires. Records of activities were documented, and a reflective diary was kept by the researcher. Seven SIG meetings were held which were less than planned-some sessions were cancelled due to general student unrest. The composition of the SIG fluctuated, but the core group of 16 students consisted of 12 females (75%) and 4 males (25%). Despite faculty-wide marketing, all the participants were medical students. The most successful marketing strategy was done by two lecturers. A total of 12 participants' motivation (75%) was to learn more about public health. Despite the range of participants being over 4-year groups with varying schedules and commitments, a convenient day and meeting time were identified. The social capital of lecturers was harnessed to invite external guest lecturers as planned field trips proved impractical. At the mid-year point, six students (38%) thought that they would consider public health as a career choice. A decision was made to recruit new members via a seminar, and 37 possible new members were identified in the process. CONCLUSIONS: A SIG appears to be an effective strategy to increase public health interest among students. This finding is key in settings with particular health workforce shortages and high burdens of disease. A foundation phase with high levels of academic support by those already qualified is needed to allow student leadership to emerge. Despite the modified and reduced number of sessions, the SIG was still successful in increasing awareness about public health and possible career choices: both positive consequences of engaging with students within a SIG.