Poor Health Behaviour in Medical Students at a South African University: A Cross-Sectional Survey Study.

BACKGROUND: Personal health behaviours and lifestyle habits of health professionals influence their counselling practices related to non-communicable diseases (NCDs). There are limited data on the prevalence of unhealthy lifestyle habits among medical students and the impact of acquired health knowledge throughout the curriculum. The aim of this study was to determine and compare the prevalence of modifiable behavioural NCD risk factors of medical students in different academic years at a South African tertiary institution. METHODS: A cross-sectional observational study of 532 consenting medical students was conducted. Participants completed five online questionnaires regarding lifestyle behaviours (physical activity, dietary habits, smoking, alcohol consumption and sleep). RESULTS: Lifestyle-related risk factors with the highest prevalence were poor sleep quality (66.0%), low levels of habitual physical activity (55.8%) and low-to-moderate diet quality (54.5%). There were no differences between academic years for all risk factors measured. Over 60% of the cohort had two or more NCD risk factors and this prevalence did not differ across the degree program with the acquisition of more health knowledge. CONCLUSION: Medical students have a high prevalence of poor sleep quality, low levels of physical activity and low-to-moderate diet quality, which does not appear to change over the course of their academic career. Sleep hygiene, regular physical activity and healthy nutrition should be targeted in intervention programmes and be more prevalent in the medical curriculum.

Position paper on undergraduate Palliative Medicine education for doctors in South Africa.

BACKGROUND:  Basic palliative care teaching should be included in training curricula for health care providers (HCPs) at all levels of the health service to ensure that the goal set by the South African (SA) National Policy Framework and Strategy for Palliative Care, to have an adequate number of appropriately trained HCPs in South Africa, is achieved. Furthermore, palliative learning objectives for nurses and doctors should be standardised. Many SA medical schools have integrated elements of Palliative Medicine (PM) teaching into undergraduate medical training programmes for doctors; however, the degree of integration varies widely, and consensus and standardisation of the content, structure and delivery of such PM training programmes are not yet a reality. AIM:  This joint position paper aims to describe the current state of undergraduate medical PM teaching in South Africa and define the PM competencies required for an SA generalist doctor. SETTING:  Palliative Medicine programme leads and teachers from eight medical schools in South Africa. METHODS:  A survey exploring the structure, organisation and content of the respective medical undergraduate PM programmes was distributed to PM programme leads and teachers. RESULTS:  Responses were received from seven medical schools. Through a process of iterative review, competencies were defined and further grouped according to suitability for the pre-clinical and clinical components of the curriculum. CONCLUSION:  Through mapping out these competencies in a spiralled medical curriculum, the authors hope to provide guidance to medical curriculum designers to effectively integrate PM teaching and learning into current curricula in line with the goals of the SA National Policy Framework and Strategy on Palliative Care (NPFSPC).

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.

The quality of voluntary medical male circumcision done by mid-level workers in Tshwane District, South Africa: A retrospective analysis.

BACKGROUND: Voluntary medical male circumcision (VMMC) reduces the acquisition of human immunodeficiency virus (HIV) in heterosexual men by up to 60%. One HIV infection is averted for every 5 to 15 VMMCs. To conduct VMMCs in large populations, large numbers of trained healthcare professionals are needed. Countries in Sub-Saharan Africa have a high burden of HIV and a shortage of healthcare professionals, creating a healthcare conundrum. To bridge this gap, South Africa launched a new cadre of mid-level medical worker called Clinical Associates (CA). We assessed the ability of CAs to perform circumcisions of adequate quality and their subsequent usefulness to meet the demands of VMMCs in a population with a high HIV burden. METHODS: We conducted a retrospective analysis, reviewing patient files (n = 4850) of surgical VMMCs conducted over a 16-month period. Patient files were sourced from clinics and hospitals that provided free VMMCs in Tshwane district in South Africa. FINDINGS: Clinical associates performed 88.66% of the circumcisions and doctors performed the remaining 11.34% (p < 0.001). The number of adverse events did not differ between the two groups. Data on intra-operative adverse events were available for 4 738 patients. Of these, 341 (7.2%) experienced intra-operative adverse events. For the whole sample, 44 (8.1%, n = 543) adverse events occurred during circumcisions done by doctors and 297 (7.1%, n = 4195) occurred during circumcisions done by CAs (p = 0.385). Clinical associates performed circumcisions in shorter times (duration: 14.63 minutes) compared to doctors (duration: 15.25 minutes, t = -7.46; p < 0.001). Recorded pain, bleeding, swelling, infection and wound destruction did not differ between clients circumcised by CAs and doctors. This study is limited by the use of data from a single district. CONCLUSIONS: Clinical associates contribute to the demands for high numbers of VMMCs in Tshwane district, South Africa. Clinical associates perform VMMCs at a clinical standard that is comparable to circumcisions performed by doctors.

Students' perceptions of the instructional quality of district hospital-based training.

BACKGROUND: An innovative, three-year training programme, the Bachelor of Clinical Medical Practice (BCMP), for mid-level medical healthcare workers was started in 2009 by the Department of Family Medicine, University of Pretoria. AIM: To measure the students' perceptions of the instructional quality of district hospitalbased training. SETTING: Training of students took place at clinical learning centres in rural district hospitals in the Mpumalanga and Gauteng provinces. METHODS: A survey using the MedEd IQ questionnaire was performed in 2010 and 2011 to measure BCMP second- and third-year students' perceptions of instructional quality of district hospital-based training. The MedEd IQ questionnaire is composed of four subscales: preceptor activities, learning opportunities, learner involvement and the learning environment. Composite scores of instructional quality were used to present results. RESULTS: The preceptor activities, learning opportunities and the learning environment were considered by second- and third-year BCMP students to be of consistently high instructional quality. In the area of learner involvement, instructional quality increased significantly from second to third year. CONCLUSION: Overall, instructional quality of district hospital-based training was high for both second- and third-year BCMP students, and the instructional quality of learner involvement being significantly higher in third year students. The MedEd IQ tool was a useful tool for measuring instructional quality and to inform programme quality improvement.

"Making a difference" - Medical students' opportunities for transformational change in health care and learning through quality improvement projects.

BACKGROUND: Quality improvement is increasingly becoming an essential aspect of the medical curriculum, with the intention of improving the health care system to provide better health care. The aim of this study was to explore undergraduate medical students' experiences of their involvement in quality improvement projects during a district health rotation. METHODS: Student group reports from rotations in learning centres of the University of Pretoria in Mpumalanga Province, South Africa were analysed for the period 2012 to 2015. Interviews were conducted with health care providers at four learning centres in 2013. RESULTS: Three main themes were identified: (1) 'Situated learning', describing students' exposure to the discrepancies between ideal and reality in a real-life situation and how they learned to deal with complex situations, individually and as student group; (2) 'Facing dilemmas', describing how students were challenged about the non-ideal reality; (3) 'Making a difference', describing the impact of the students' projects, with greater understanding of themselves and others through working in teams but also making a change in the health care system. CONCLUSION: Quality improvement projects can provide an opportunity for both the transformation of health care and for transformative learning, with individual and 'collective' self-authorship.

Cost effectiveness of clinical associates: A case study for the Mpumalanga province in South Africa.

BACKGROUND: The National Department of Health of South Africa decided to start a programme to train mid-level healthcare workers, called clinical associates, as one of the measures to increase healthcare workers at district level in rural areas. Unfortunately, very little is known about the cost effectiveness of clinical associates. AIMS: To determine, on a provincial level, the cost effectiveness of training and employing clinical associates and medical practitioners compared to the standard strategy of training and employing only more medical practitioners. METHODS: A literature study was performed to answer several sub questions regarding the costs and effectiveness of clinical associates. The results were used to present a case study. RESULTS: The total cost for a province to pay for the full training of a clinical associate is R 300 850. The average employment cost per year is R196 329 and for medical practitioners these costs are R 730 985 and R 559 397, respectively.Effectiveness: Clinical associates are likely to free up the time of a medical practitioner by 50-76%. They can provide the same quality of care as higher level workers, provided that they receive adequate training, support and supervision. Furthermore, they seem more willing to work in rural areas compared to medical practitioners. CONCLUSIONS: The case study showed that training and employing clinical associates is potentially a cost-effective strategy for a province to meet the increasing demand for rural healthcare workers. This strategy will only succeed when clinical associates receive adequate training, support and supervision and if the province keeps investing in them.

Medical education and the quality improvement spiral: A case study from Mpumalanga, South Africa.

BACKGROUND: The short timeframe of medical students' rotations is not always conducive to successful, in-depth quality-improvement projects requiring a more longitudinal approach. AIM: To describe the process of inducting students into a longitudinal quality-improvement project,using the topic of the Mother- and Baby-Friendly Initiative as a case study; and to explore the possible contribution of a quality-improvement project to the development of student competencies. SETTING: Mpumalanga clinical learning centres, where University of Pretoria medical students did their district health rotations. METHOD: Consecutive student groups had to engage with a hospital's compliance with specific steps of the Ten Steps to Successful Breastfeeding that form the standards for the Mother- and Baby-Friendly Initiative. Primary data sources included an on-site PowerPoint group presentation (n = 42), a written group report (n = 42) and notes of individual interviews in an end-of-rotation objectively structured clinical examination station (n = 139). RESULTS: Activities in each rotation varied according to the needs identified through the application of the quality-improvement cycle in consultation with the local health team. The development of student competencies is described according to the roles of a medical expert in the CanMEDS framework: collaborator, health advocate, scholar, communicator, manager and professional. The exposure to the real-life situation in South African public hospitals had a great influence on many students, who also acted as catalysts for transforming practice. CONCLUSION: Service learning and quality-improvement projects can be successfully integrated in one rotation and can contribute to the development of the different roles of a medical expert. More studies could provide insight into the potential of this approach in transforming institutions and student learning.