Tenofovir disoproxil fumarate associated nephrotoxicity: a retrospective cohort study at two referral hospitals in Namibia.

INTRODUCTION: The incidence and risk factors of tenofovir disoproxil fumarate (TDF)-related renal impairment (RI) in Namibia are unknown where TDF-containing ART regimens are used as the first line for HIV. METHODOLOGY: A retrospective cohort study among HIV-infected patients at two intermediate hospitals. A decline in estimated glomerular filtration rate (eGFR) was significant if it was ≥25% and included a change to a lower eGFR stage. New-onset RI was defined as an eGFR <50 mL/min/1.73m2 . RESULTS: 10 387 patients were included: 11.4% (n = 1182) experienced the decline in eGFR. Of these, 0.6% (n = 62) migrated to eGFR stages IV and V. The incidence was 4.5 (95% CI: 4.3-4.8) per 100 patient years. RI developed in 400 patients for an incidence rate of 2.4 (95% CI: 2.2-2.6) cases per 100 patient years. Risk factors with effect sizes >2.0, for decline-in-eGFR were baseline eGFR >60 (aHR = 15.6); hyperfiltration (aHR = 5.0); and pregnancy (aHR = 2.4); while for RI, they were hyperfiltration (aHR = 4.1) and pregnancy (aHR = 29). CONCLUSION: The incidence of decline-in-eGFR was higher than in other sub-SSA countries, but not RI. A high baseline eGFR had the greatest risk for the decline, and hyperfiltration for the RI.

Corn? When did I eat corn? Gastrointestinal transit time in health science students.

The objective of this study was to determine gastrointestinal transit time in first-year health science students with a laboratory practical exercise conducted in two cohorts (classes of 2018 and 2019) of first-year health sciences students at the Health Science Campus in Windhoek, Namibia. All first-year health science students undertaking the Physiology course were invited to take part in the laboratory exercise. The primary outcome was the measurement of gastrointestinal transit time from the amount of time taken for ingested whole-kernel sweetcorn to be eliminated, which was calculated as the time period between ingestion of corn and the time of corn first seen in the stool and the time corn was last seen in the stool. The secondary outcome was an association between emotional irritability and/or anxiety and gastrointestinal transit time. The study analyzed responses of 175 students, who reported a median transit time of 29 (1-99) h. There was no difference in gastrointestinal transit time between male and female students. Likewise, there was no difference in the duration of the corn in the bowel between male and female students. Students who reported being worried and irritable during the exercise had more bowel movements before they saw corn in their stool and had slower transit times, respectively. A wider range of transit time was reported in a group of young, healthy students compared with previous studies in the literature. There were no differences between male and female student bowel activity. Anxiety did impact the bowel activity of the participants.

Reflecting on interprofessional education in the design of space and place: lessons from Namibia.

Education at the University of Namibia, School of Medicine and School of Pharmacy relies on a community-centred curriculum. The aim is to nurture "7-star" doctors and pharmacists that will address the current social and health needs within the country. A sound understanding of the interplay between learning and the learning environment is said to improve interprofessional educational activities. This relationship is dependent on constrictive alignment of not only the aspects of pedagogy, but also that of educational leadership in context of the current and social health needs. In this report, we reflect on the interprofessional-learning environment that was created out of necessity within a Namibian context.

Regional climate influences manure temperature and methane emissions - A pan-Canadian modelling assessment.

This study explores the variation of liquid manure temperature (Tm) and CH4 emissions associated with contrasting regional climates, inter-annual weather variation, and manure storage emptying. As a case-study, six regions across Canada were used, spanning 11°32' latitude and 58°30' longitude. Annual average air temperatures ranged from 3.9 °C (prairie climate) to 10.5 °C (maritime climate), with an overall average of 6.6 °C. A model predicted Tm over 30 years, using daily weather (1971-2000), and over one "normal" year (30-year average weather). Modelled Tm was then used in Manure-DNDC to model daily CH4 emissions. Two manure storage emptying scenarios were simulated: (i) early spring and autumn, or (ii) late spring and autumn. Regional differences were evident as average Tm ranged from 8.9 °C to 14.6 °C across the six locations. Early removal of stored manure led to warmer Tm in all regions, and the most warming occurred in colder regions. Regional climate had a large effect on CH4 emissions (e.g. 1.8× greater in the pacific maritime and great lakes regions than the prairie region). Inter-annual weather variability led to substantial variation in inter-annual CH4 emissions, with coefficient of variation being as high as 20%. The large inter-annual range suggests that field measurements of CH4 emissions need to compare the weather during measurements to historical normals. Early manure storage emptying reduced CH4 emissions (vs late removal) in some regions but had little effect or the opposite effect in other regions. Overall, the results from this modelling study suggest: i) Tm differs substantially from air temperature at all locations, ii) accurate estimates of manure storage CH4 emissions require region-specific calculations using Tm (e.g. in emission inventories), iii) field measurements of CH4 emissions need to consider weather conditions relative to climate normal, and iv) emission mitigation practices will require region-specific measurements to determine impacts.

Optimizing spontaneous adverse drug reaction reporting in public healthcare setting in Namibia.

Despite the universal scale-up of pharmacovigilance systems globally, adverse drug reaction (ADR) reporting remains suboptimal among resource-limited countries. Few studies in sub-Saharan Africa evaluate the effectiveness of adverse drug reaction (ADR) reporting programmes. A cross-sectional survey using a self-administered questionnaire to assess ADR reporting knowledge, attitude and practices among healthcare workers in Namibia's public sector was conducted between September and December 2018. The primary outcome were practices, knowledge and attitude of the respondents towards ADR reporting. Quantitative and qualitative data were analysed using descriptive statistics and thematic analysis, respectively. Of the 197 healthcare workers surveyed, 43.1% were nurses, 63.4% of the respondents knew about the ADR reporting system in Namibia, 76.7% knew the pharmacovigilance/ADR reporting centre in Namibia, while 37.3% had reported an ADR before. Nurses were less likely to be knowledgeable and report ADRs. The independent predictor of ADR reporting was the nursing cadre; adjusted odds ratio (aOR) = 0.17 (95% CI: 0.07, 0.401, P < .01). Pre- and in-service trainings including introduction of electronic reporting platforms were some of the identified ways of optimizing the pharmacovigilance and ADR reporting systems by the respondents. As pharmacovigilance in Namibia relies on spontaneous reporting of ADRs, there is a need for advocacy and workforce strengthening for ADR reporting in the public health sector.

A model to strengthen utility of quality pharmaceutical health systems data in resource-limited settings.

Background: Limited utility of quality health data undermines efforts to strengthen healthcare delivery, particularly in resource-limited settings. Few studies model the effective utility of quality pharmaceutical information system (PIS) data in sub-Saharan Africa, typified with weak health systems. Aim: To develop a model and guidelines for strengthening utility of quality PIS data in public healthcare in Namibia, a resource-limited setting. Methods: A qualitative model based on Dickoff et al. practice-oriented theory, Chinn and Jacobs' systematic approach to theory, and applied consensus techniques. Data from nationwide studies on quality and utility of PIS data in public healthcare conducted between 2018 and March 2020 informed the development of the model concepts. Pharmaceutical and public health systems experts validated the final model. Results: Overall, four preliminary national studies that recruited 58 PIS focal persons at 38 public health facilities and national level informed the development of four model concepts. The model describes concepts on access, management, dissemination, and utility of quality PIS data. Activities to implement the model in practice include grass-root integration of real-time automated pharmaceutical intelligence systems to collect, consolidate, monitor, and report PIS data. Strengthening coordination, human resources, and technical capacity through support supervisory systems at grass-root facilities are key activities. PIS focal persons at health facility and national level are agents to implement these activities among recipients, that is, healthcare professionals at points of care. Guidelines for implementation of the model at point of care are included. Experts described the model as clear, simple, comprehensive, and integration of pharmaceutical intelligence systems at point of care as novel and of importance to enhance utility of quality PIS data in resource-limited settings. Conclusion: While utility of quality PIS data is limited in Namibia, advantages of the model are encouraging, toward building resilient pharmaceutical intelligence systems at grass roots in resource-limited countries, where there are not only weak health systems, but high burden of misuse of medicines.

Patient experiences in managing non-communicable diseases in Namibia.

INTRODUCTION: The prevalence of non-communicable diseases (NCDs) is rising in Namibia, and with it, the need for pharmacists to empower patients. This research aims to 1) identify patient-reported barriers and facilitators to managing chronic NCDs for Namibians, and 2) characterize common patient-reported medication and health-related needs of Namibians with chronic NCDs. METHODS: This qualitative study used semi-structured interviews to elicit participant perspectives regarding NCDs. The study used the conceptual frameworks of the Health Belief Model, the Theory of Planned Behavior, and the Explanatory Models of Illness to identify and understand key factors necessary to develop relevant patient-centered interventions. Participants were recruited from pharmacies throughout Namibia. Data were analyzed using thematic analysis from the transcribed interviews. RESULTS: A total of 23 interviews were conducted, with 20 being included in the final analysis. Themes identified included: 1) participants were motivated to seek care when they were symptomatic; 2) participants felt motivated to care for their condition to improve their own lives and their families for their family's sake; 3) participants integrated information from a variety of sources into their disease knowledge; 4) participants describe wanting to be more engaged in managing their health and wanting support to help manage their condition; 5) participants describe awareness of lifestyle changes necessary to improve health, but face many barriers to achieving them. CONCLUSION: This study identified key factors that are essential for pharmacists and other health care professionals to be aware of in order to support patients who are diagnosed with an NCD. Health care providers should consider strategies to engage patients to harness their motivations, enhance health education, and create systems to reduce barriers to addressing lifestyle.

Developing a grass-roots method for monitoring medicines shortages in southern Africa: Report of a pilot in Namibia.

Shortages of medicines is a global problem that can have significant impact on health outcomes of patients and reduce the effectiveness of public health programmes. There are a multitude of reasons for medicines shortages occurring, however, and it is important for specific country settings to better understand the issues affecting medicines supply in order to effectively intervene. Namibia relies heavily on imports of medicines as it does not have an adequate pharmaceutical industry sector developed enough to produce sufficient medicines for the burden of disease arising. In addition, because there is no unifying system of medicines monitoring it is difficult to plan interventions to resolve common medicines shortages. This study reports the findings from a pilot survey that was undertaken to improve the information monitoring of medicines shortages in Namibia. The survey sought information from medicines suppliers from various pharmacy sectors who may provide a vital insight into how medicines shortages should be monitored and the causes of shortages observed in Namibia. A more robust survey as part of a broader system can be informed by this survey to address the shortage of medicines in Namibia and surrounding region.

Effective integration of pharmacovigilance systems at public health facilities in resource-limited settings: A qualitative study.

BACKGROUND: Pharmacovigilance systems increase access to safe medicines and healthcare, but their integration in public healthcare remains a challenge in many countries. The main barriers to pharmacovigilance integration are attributed to high patient load and limited capacities. OBJECTIVE: To explore the challenges associated with the effective integration of pharmacovigilance systems in public healthcare in a developing country such as Namibia. METHODS: A nationwide qualitative assessment of integration of pharmacovigilance systems particularly spontaneous adverse drug reaction (ADR) reporting at public health facility level was conducted. Key informant interviews were conducted among pivotal healthcare professionals involved in pharmacovigilance. The main outcomes were themes on challenges and strategies for effective integration of PV services at the facility level. Qualitative data were collected over a one-month period (i.e., March 2019), and thematically analysed. RESULTS: Eight (8) key informants were recruited; the majority were pharmacists (n = 7) and male (n = 5). The main challenges affecting the effective integration of pharmacovigilance systems reporting at public health facilities were "weak pharmacovigilance policies and structures", "negative attitude of healthcare workers towards pharmacovigilance", and "limited capacity and support for implementation of pharmacovigilance activities". The main strategies for effective integration of PV systems at facilities included local capacity-building through continuing profession education and support, advocacy, stakeholder engagement, facility/region based pharmacovigilance champions, and facility-based policies for universal and inclusive reporting, (i.e. patients and health workers at all levels) as well as development of workable standard operational procedures. CONCLUSIONS: The pharmacovigilance systems at healthcare facilities in Namibia were observed to have sub-optimal policies, structures and support systems, and lack health care worker buy-in. There is a need for a policy framework to ensure effective and sustainable integration of pharmacovigilance activities at public healthcare facilities.

Protein Identification of Venoms of the African Spitting Cobras, Naja mossambica and Naja nigricincta nigricincta.

Cobra snakes, including Naja mossambica and Naja nigricincta nigricincta, are one of the major groups of snakes responsible for snakebites in southern Africa, producing significant cytotoxicity and tissue damage. The venom of N. mossambica has been briefly characterised, but that of N. n. nigricincta is not reported. The current study identifies the venom proteins of N. mossambica and N. n. nigricincta. This is achieved using sodium dodecyl sulphate (SDS)-polyacrylamide gel eletrophroresis (PAGE), followed by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Most of the proteins were less than 17 kDa in both snakes. N. mossambica was found to have 75 proteins in total (from 16 protein families), whereas N.n. nigricincta had 73 (from 16 protein families). Of these identified proteins, 57 were common in both snakes. The proteins identified belonged to various families, including the three-finger toxins (3FTx), Cysteine-rich secretory proteins (CRiSP), Phospholipase A2 (PLA2) and Venom metalloproteinase M12B (SVMP). The current study contributes to the profile knowledge of snake venom compositions, which is of fundamental value in understanding the proteins that play a major role in envenomation.

Predictors of loss to follow-up of tuberculosis cases under the DOTS programme in Namibia.

BACKGROUND: In Namibia, one out of every 25 cases of tuberculosis (TB) is "lost to follow-up" (LTFU). This has impacted negatively on national efforts to end the disease by 2035. The aim of this study was to determine the trends and predictors of LTFU under the directly observed treatment short-course (DOTS) programme in Namibia. METHODS: The study involved a retrospective longitudinal analysis of a nationwide cohort of TB cases registered under the DOTS programme in Namibia from 2006 to 2015. The trends and predictors of LTFU among cases in the National Electronic TB Register of the National TB and Leprosy Program were respectively determined by interrupted time series and multivariate logistic regression analyses using R-Studio software. RESULTS: Out of 104 203 TB cases, 3775 (3.6%) were LTFU. A quarter (26%) of cases with poor outcomes were due to LTFU. The annual decline in cases of LTFU was significant between the first (2005-2010) and second (2010-2015) medium-term plan period for TB programme implementation (p=0.002). The independent predictors of LTFU were male sex (p=0.004), 15-24 years age group (p=0.03), provider of treatment (p<0.001), intensive phase (p=0.047) and living in border/transit regions (p<0.001). HIV co-infection and TB regimen were not significant predictors of LTFU. CONCLUSIONS: There were declining trends in LTFU in Namibia. DOTS programmes should integrate socioeconomic interventions for young and middle-aged adult male TB cases to reduce LTFU.

A pragmatic approach to introducing mixed methods research training for pharmacy students in Namibia.

BACKGROUND AND PURPOSE: Pharmacy and medical training were introduced for the first time in Namibia in 2011 and 2010 respectively. All students must complete a research project as part of their training, which is supported by various courses in the respective curricula including research methods. Following a revision of the medical curriculum, there was an opportunity to review the way research methods was taught for both degrees, piloting in pharmacy then expanding to other disciplines. An educational activity that was part of the research methods course for training pharmacy students in Namibia is described. EDUCATIONAL ACTIVITY AND SETTING: The activity described related to a new approach in the running of the research methods course for pharmacy students and included, in a portfolio-based approach, a group project. Students were tasked to collect qualitative data from medical student colleagues that they then needed to codify and ultimately articulate into a survey questionnaire. The questionnaire was subsequently sent out to collect responses on medicines-related items that could be analyzed quantitatively in subsequent teaching sessions. Supportive lectures, tutorials and portfolio assignments were provided during the project. Data were collected the following year to create a more substantive dataset and a screencast video made to benefit future students in the course. FINDINGS AND DISCUSSION: Through the course of this activity students developed a questionnaire survey tool based on qualitative responses to brief interviews with medical students and emergent themes based on qualitative analyses. A dataset was created that allowed demonstration of quantitative analyses and extraction of sub-scales from the questionnaire. Further educational resources were developed to ensure sustainability of this educational resource and retention in the taught curriculum. SUMMARY: The current article discusses the development, implementation and evaluation of this research methods course component. The application of data collected as part of the activity and its relevance to the educational activity is examined as well as lessons learned for the future running of the project and further evaluation.

Creating clinical pharmacy capacity in Namibia: a collaboration to establish a post-graduate pharmacy degree programme.

Namibia has previously relied on external training of pharmacists but began in-country training in 2011. In response to an identified need for postgraduate clinical pharmacy development and training in the country, a Master's degree was set up at the University of Namibia in 2016. The country has a considerable health burden of HIV and TB as well as a shortage of healthcare professionals. A UK clinical diploma model was adapted to meet the specific needs of the country and wider region, ensuring students could access the course over a sparsely populated, but large geographical spread, in addition to providing work-based learning, embedding research skills for future development, and focusing on the health needs of Namibia. The course uses online learning platforms and contact sessions to cover both knowledge and skill acquisition throughout the 3 years of the course. UK and US clinical pharmacists are utilised to provide specialist input, both remotely and within student workplaces, and further support has come from collaborations, including cross-site visits, with the UK-based pharmacy school whose diploma model was adapted. Challenges have included a shortage of clinical mentors, also compounding the students' difficulty in visualising their future roles, as well as lone practitioners finding it hard to attend all contact sessions. The initial dropout rates of earlier cohorts have since reduced with greater understanding of the programme, and enthusiasm for the course remains high. The aim for the Master's is to train students to become competent clinical pharmacists, thus having the knowledge and skills to mentor future cohorts of the course, as well as expanding the specialty within the country.

Competency (and Beyond): Think Patient. Collaborate. Develop. Evaluate. Improve. Repeat.

The global workforce needs to be competent, flexible, adaptable, sustainable, and patient-focused. A competency approach towards education, development, and professional practice strengthens services and increases better health outcomes. This paper will provide a global perspective on competency approaches from different health care professions. It will focus on two case reports, describing the use of competency methodologies at an undergraduate and postgraduate level, as well as supporting the internship and/or pre-registration training. Challenges and opportunities will be highlighted by addressing some of the key questions posed for this special edition.

Evidence-Responsive Health Training to HIV/TB Risks in Namibia.

Training health-care students in settings with high-prevalence HIV and tuberculosis (TB) presents a challenge to reduce the risk of infection during their clinical training while maintaining quality education. We sought to gauge the risk of exposure to HIV and TB and identify associated variables through two cross-sectional surveys of health students at the University of Namibia. In the HIV exposure survey, overall almost one-quarter of students (N = 367) reported exposure to HIV-most often needle-stick injury-with a much higher rate reported in senior years (73% in year 6). One in 10 students responding to the TB survey were found to have been exposed to TB (N = 290). Regression analyses suggested that time-related factors were a common predictor of risk of both HIV and TB in this setting. We consider that the overall exposure rate to HIV and TB was high, suggesting that training could be improved to reduce the risks of exposure.

Health workforce planning in Namibia: assessing a pilot workforce survey of pharmacists.

BACKGROUND: Southern Africa lacks resources necessary to combat presenting health challenges. This crisis will likely be remedied through the in-country training of healthcare professionals, for example, in Namibia. Monitoring the workforce will be essential to inform planning in health services and training. A national pilot workforce survey in Namibia using a multi-modal sampling approach aimed to test methodology for describing the pharmacy workforce and quantifying preferences towards further training. METHODS: The survey tool included questions relating to socio-demographics, professional and practice aspects. A conjoint analysis approach was utilised to quantify preferences around study programme, modality of study and cost. KEY FINDINGS: Respondents (N = 135; ~20% response) represented a diverse range of individuals in various pharmacy sectors in Namibia. The majority of respondents reported female gender, private sector working, studying outside Namibia and societal group membership. Societal membership and pharmacy ownership - indicators of professional engagement - were associated with higher age; ownership was also associated with study outside Namibia and practice in community pharmacy. Regarding further study preferences, respondents placed more importance on study programme and modality over cost with the most preferred scenario being a 2-year full-time Masters programme in pharmaceutical industry/regulation by distance learning at the highest cost bracket. CONCLUSIONS: This national survey sampled the population of pharmacists in Namibia exploring the composition of the profession and preferences towards training. Further work will validate the findings and provide ongoing monitoring of the pharmacy workforce that can be expanded to other professional groups over a larger geographical area.

Health students' knowledge and infectious disease exposure: findings from a cross-sectional study in Namibia.

BACKGROUND: Namibia has recently introduced a number of health training programmes that expose students to infectious disease risks such as human immunodeficiency virus (HIV) and tuberculosis (TB). We explored the knowledge of students in relation to HIV and TB and whether or not there was evidence of exposure. METHODS: We conducted two cross-sectional surveys of Namibian health students (medicine and pharmacy) in 2018. RESULTS: There was a strong association between knowledge and exposure to HIV, but not TB (i.e. explicit exposure versus latent). Regression analysis suggested the time-related risk (age/year of study) to be predictive of knowledge in both studies. The training rotation in the respiratory unit predicted TB knowledge and post-exposure prophylaxis predicted HIV knowledge. CONCLUSIONS: Knowledge of TB and HIV appears mostly related to the duration of study in health students. Exposure or specific experience may enhance knowledge. Future training in infection control may be better focussed on improving knowledge in earlier years.

A pragmatic approach ensuring accuracy in language translation in tuberculosis research.

BACKGROUND: To research patient perceptions of medicines and illness in a multicultural setting, it is appropriate to translate research materials. However, the translation procedures should be valid and reliable to assure accuracy. OBJECTIVES: To translate into 3 languages-Turkish, Urdu, and Bengali-a research questionnaire investigating illness and medicines perceptions of tuberculosis patients and to validate the translation. METHODS: A 4-stage protocol for the translation and validation of research questionnaires investigating illness and medicines perceptions was designed and implemented. This involved forward and back-translation, group-validation, and post hoc conceptual equivalence rating in 3 different languages. RESULTS: The translation protocol was found to be very useful in identifying discrepancies between original and translated versions; a total of 83 amendments were required. Post hoc evaluations also demonstrated improvements for 2 of the 3 language translations. Some redundancy was apparent and an improved protocol was suggested by the authors. CONCLUSIONS: This study demonstrated that including a protocol for translation and validation of the translation is crucial to assure accuracy in multicultural research.