Transformative learning through participation: experiences at a rural clinical training site in South Africa.

BACKGROUND: Distributed training has been cited as an opportunity that offers transformative learning experiences in preparing a future workforce to address local needs. For this reason, rural and longitudinal placements are increasingly being adopted by medical schools across the world. Place, participation and person are considered integral in the process of transformation of medical students into responsive graduates on the distributed platform. This article aims to explore the experiences and perceptions of student learning on a rural training platform in South Africa while considering the interrelation between person, place and participation as a process of transformation to becoming a health care professional. The research forms part of a 5-year longitudinal case study, initiated in 2019 to explore a university-rural hospital collaboration on students, staff and the local health care system. METHODS: Data was collected using interviews and surveys from 63 purposively selected and consenting participants between January and November of 2019. All qualitative data were inductively analysed using an interpretivist approach to thematic analysis for the purposes of this article. All quantitative data was analysed descriptively using Microsoft Excel. Ethics and permission for this research was granted by the Stellenbosch University Human Research Ethics Committee, the Undergraduate Students Programme Committee and the Northern Cape Department of Health, South Africa. FINDINGS: Four themes, namely: authenticity of context; participation in a community of practice and social activities; supervision and reflection; and distance support were extracted from the data. These findings contribute to the theory of transformative learning on the distributed platform by expanding on the interrelationship of person, place and participation, specifically as it relates to participation within various communities and practices. The value of active participation in reflection and supervision, distance academic support and social support systems are explored. CONCLUSIONS: The three dimensions and interrelationship of person, place and participation in the process of transformative learning on the rural training platform can be further unpacked by exploring the types of participation that have facilitated student learning in this research context. Participation in interprofessional teams; supervision, reflection and distance support appear to be the most crucial elements during this transformative learning process.

Exploring literature on knowledge, attitudes, beliefs and practices towards urinary incontinence management: a scoping review.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence affects women of all ages, influencing 8.5% of the world's population in 2018. Effective management of urinary incontinence is influenced by patients help-seeking behaviour and services offered by healthcare professionals within the healthcare system. To facilitate behavioural change, it is important to understand the knowledge(Knowledge: "the comprehension and understanding of acquired facts or information about UI in adults"), attitudes (Attitude: "a predisposed perspective which influences nurses' thoughts, feelings, perceptions and behaviours towards care of adults with UI") and beliefs (Beliefs: "a theoretically conceptualized conviction or expectation regarding UI in general") of healthcare practitioners towards urinary incontinence management. The aim of this review is thus to systematically map the existing literature, reporting on how knowledge, attitude, belief and practices towards urinary incontinence management have been explored. METHODS: Six databases were systematically searched. Included studies were published between January 2013 to January 2020 in English, investigating urinary incontinence management in women. RESULTS: The search yielded 39 studies, with data emanating from 16 counties. Quantitative, Qualitative and mixed methodologies were used to explore the four concepts of knowledge, attitudes, beliefs and practices. A wide range of healthcare practitioners were questioned and management was explored in five healthcare settings. All factors explored related to the four concepts are reported and factors reaching consensus in included literature were highlighted. CONCLUSION: The summarized factors can assist further investigations into the four concepts to change healthcare practitioner's behaviour towards urinary incontinence management.

The use of periodized exercise prescription in rehabilitation: a systematic scoping review of literature.

OBJECTIVE: To describe the use of periodized exercise prescription with patients in the context of rehabilitation. DATA SOURCE: The following databases were searched: The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, CINAHL, ScienceDirect, PEDro, Web of Science, SPORTDiscus, SAGE and Google Scholar. Databases were searched from inception to March 2018. RESULTS: The literature search yielded 1772 articles with 1755 being excluded leaving 17 articles in total for the full review. Methodological quality and internal validity of the included papers were lacking. The included studies failed to indicate in which phase rehabilitation had occurred. Programme structure relating to the use of a familiarization phase, sequencing of exercises and structuring of specific phases (i.e. macrocycle, mesocycle and microcycle) was not present and lacked consistency across the board. CONCLUSION: Periodization models of exercise prescription are being used within a variety of population groups in the rehabilitation setting. Integration of periodization principles into a rehabilitation programme still however remains a challenge. Although there is a lack of consistency with regard to the structure and implementation of a periodized model of exercise prescription in the rehabilitation context, it seems to be an alternative way in which to prescribe exercise within the rehabilitation setting.

Ethnic differences in pelvic floor muscle strength and endurance in South African women.

INTRODUCTION AND HYPOTHESIS: Limited knowledge exists about pelvic floor muscle (PFM) function in ethnic groups. The aim of this study was to compare PFM strength and endurance in a group of black, white and mixed-race women. METHODS: This was a cross-sectional study. Maximum voluntary contraction (MVC) and endurance were measured with a perineometer and vaginal balloon sensor. Two sets of three MVC of the PFM were recorded; resting phase was 5 min. Demographic variables and factors associated with PFM strength were assessed. RESULTS: A total of 122 nulliparous black (n = 44), white (n = 44) and mixed-race (n = 34) students participated. PFM of black women were stronger than that of white (p = 0.02) or mixed-race (p < 0.01) women. The MVC of PFM in black women decreased (p = 0.02) between the first and second set of contractions. CONCLUSIONS: Ethnic differences were found. Further clinical studies are needed to confirm an association between PFM function and pelvic floor disorders.

Chronic Disease in Low-Resource Settings: Prevention and Management Throughout the Continuum of Care-A Call for Papers.

Multimorbidity, defined as the presence of two or more chronic conditions in an individual, has become a global public health challenge [...].

Public sector physiotherapists' organisation and profile: Implications for intensive care service.

Background: Physiotherapists are essential in the management of hospitalised patients. The way in which a physiotherapy service is offered in intensive care units (ICUs) can affect ICU patient outcomes. Objectives: To provide a clear picture of the organisation and structure of physiotherapy departments, the number and types of ICUs requiring physiotherapy services and the profile of physiotherapists working in South African public-sector central, regional and tertiary hospitals that house Level I-IV ICUs. Method: Cross-sectional survey design using SurveyMonkey, analysed descriptively. Results: One hundred and seventy units (the majority Level I, functioning as mixed [37%, n = 58] and neonatal [22%, n = 37] units) are serviced by 66 physiotherapy departments. The majority of physiotherapists (61.5%, n = 265) were younger than 30 years, had a bachelor's degree (95.1%, n = 408) and were employed in production Level I and community service posts (51%, n = 217) with a physiotherapy-to-hospital-bed ratio of 1:69. Conclusion: Insight into the organisational structure of physiotherapy departments and physiotherapists working in public-sector hospitals with ICU facilities in South Africa was provided. It is evident that physiotherapists employed within this sector are young and early in their career development. The large number of ICUs functioning within these hospitals and high bed-to-physiotherapist ratio is concerning, highlighting the high burden of care within this sector and the possible effect on physiotherapy services in the ICUs. Clinical implications: A high burden of care is placed on public-sector hospital-based physiotherapists. The number of senior-level posts within this sector raises concern. It is not clear how the current staffing levels, physiotherapist profile and structure of hospital-based physiotherapy departments affect patient outcomes.

Practitioner's knowledge, attitudes, beliefs and practices towards urinary incontinence.

Background: One in three women in South Africa suffer from urinary incontinence. Effective management is influenced by patients help-seeking behaviour and services offered by healthcare professionals within the healthcare system. Current practice towards urinary incontinence management in South Africa is unknown. Objectives: Our study aimed to describe and compare urinary incontinence practice and knowledge of nurses and physicians (practitioners) working in primary healthcare settings, measured against the NICE 2013 guideline and explore attitudes and beliefs towards urinary incontinence management. Method: Cross-sectional study using a self-designed online questionnaire. All primary healthcare practitioners in the Western Cape were eligible for the study. Stratified random and snowball sampling was used. Data was analysed in consultation with a statistician using SPSS. Results: Fifty-six completed questionnaires were analysed. Practitioners had an overall knowledge score of 66.7% and practice score of 68.9% compared to NICE 2013 guidelines. A lack of knowledge regarding urinary incontinence screening, following up on patients and conducting bladder diaries were noted. Pelvic floor muscle training and bladder training education was recognised as initial management but only 14.8% of practitioners referred patients to physiotherapy. Half of the sample reported being uncomfortable with urinary incontinence, although the majority wanted to learn more about urinary incontinence. Conclusion: The knowledge and practices of practitioners working at a primary healthcare level in the Western Cape are not congruent with NICE 2013 guidelines. Clinical implications: Data can be used to inform intervention planning to address urinary incontinence management at a primary healthcare level in the Western Cape.

Patient-Reported Outcome Measures in Key Sub-Saharan African Languages to Promote Diversity: A Scoping Review.

OBJECTIVES: Sub-Saharan Africa is a world region rich and diverse in cultures and languages; yet, it is also challenged with regard to resources that may facilitate the cultural adaptation or development of patient-reported outcome measures (PROMs). Systematic exclusion of patients' "voices," because of gaps in the availability of PROMs, may perpetuate health inequity. Hence, the objective is to describe the availability of PROMs in the non-English, sub-Saharan African languages. METHODS: A scoping review was conducted to identify PROMs that had been translated, validated, or developed for use in 32 selected, non-English, sub-Saharan African languages pertaining to health outcomes. Four databases were searched (May 7, 2021), and additional articles were identified through reference screening and via corresponding authors. Data were extracted in terms of country, language, population, construct, and PROM characteristics (eg, number of items). RESULTS: A total of 220 unique articles were included from 7451 records, leading to the identification of 126 unique PROMs. Most studies were conducted in either Ethiopia, Nigeria, or South Africa. As such, prevalent languages included Amharic, Yoruba, and non-English languages common to South Africa (eg, Setswana, Xhosa, and Zulu). No PROMs were identified in any of the languages for 27 sub-Saharan African countries or 10 of the 32 included languages. CONCLUSIONS: There are significant gaps in the availability of PROMs across the non-English African languages included. Nevertheless, the PROMs that were identified largely align with core outcome sets relevant to the prevalent disease burden in this world region. Consensus-based priority setting may inform the most pertinent gaps to be addressed.

The way in which a physiotherapy service is structured can improve patient outcome from a surgical intensive care: a controlled clinical trial.

INTRODUCTION: The physiological basis of physiotherapeutic interventions used in intensive care has been established. We must determine the optimal service approach that will result in improved patient outcome. The aim of this article is to report on the estimated effect of providing a physiotherapy service consisting of an exclusively allocated physiotherapist providing evidence-based/protocol care, compared with usual care on patient outcomes. METHODS: An exploratory, controlled, pragmatic, sequential-time-block clinical trial was conducted in the surgical unit of a tertiary hospital in South Africa. Protocol care (3 weeks) and usual care (3 weeks) was provided consecutively for two 6-week intervention periods. Each intervention period was followed by a washout period. The physiotherapy care provided was based on the unit admission date. Data were analyzed with Statistica in consultation with a statistician. Where indicated, relative risks with 95% confidence intervals (CIs) are reported. Significant differences between groups or across time are reported at the alpha level of 0.05. All reported P values are two-sided. RESULTS: Data of 193 admissions were analyzed. No difference was noted between the two patient groups at baseline. Patients admitted to the unit during protocol care were less likely to be intubated after unit admission (RR, 0.16; 95% CI, 0.07 to 0.71; RRR, 0.84; NNT, 5.02; P = 0.005) or to fail an extubation (RR, 0.23; 95% CI, 0.05 to 0.98; RRR, 0.77; NNT, 6.95; P = 0.04). The mean difference in the cumulative daily unit TISS-28 score during the two intervention periods was 1.99 (95% CI, 0.65 to 3.35) TISS-28 units (P = 0.04). Protocol-care patients were discharged from the hospital 4 days earlier than usual-care patients (P = 0.05). A tendency noted for more patients to reach independence in the transfers (P = 0.07) and mobility (P = 0.09) categories of the Barthel Index. CONCLUSIONS: A physiotherapy service approach that includes an exclusively allocated physiotherapist providing evidence-based/protocol care that addresses pulmonary dysfunction and promotes early mobility improves patient outcome. This could be a more cost-effective service approach to care than is usual care. This information can now be considered by administrators in the management of scarce physiotherapy resources and by researchers in the planning of a multicenter randomized controlled trial. TRIAL REGISTRATION: PACTR201206000389290.

Reaching consensus on the physiotherapeutic management of patients following upper abdominal surgery: a pragmatic approach to interpret equivocal evidence.

BACKGROUND: Postoperative pulmonary complications remain the most significant cause of morbidity following open upper abdominal surgery despite advances in perioperative care. However, due to the poor quality primary research uncertainty surrounding the value of prophylactic physiotherapy intervention in the management of patients following abdominal surgery persists. The Delphi process has been proposed as a pragmatic methodology to guide clinical practice when evidence is equivocal. METHODS: The objective was to develop a clinical management algorithm for the post operative management of abdominal surgery patients. Eleven draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n=5) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus-semi-interquartile range (SIQR)<0.5-were collated into the algorithm. RESULTS: The five panelists allocated to the abdominal surgery Delphi panel were from Australia, Canada, Sweden, and South Africa. The 11 draft algorithm statements were edited and 5 additional statements were formulated. The panel reached consensus on the rating of all statements. Four statements were rated essential. CONCLUSION: An expert Delphi panel interpreted the equivocal evidence for the physiotherapeutic management of patients following upper abdominal surgery. Through a process of consensus a clinical management algorithm was formulated. This algorithm can now be used by clinicians to guide clinical practice in this population.

A modified six-minute walk test (6MWT) for low-resource settings-a cross-sectional study.

BACKGROUND: The 6 min walk test (6MWT) is a validated tool used to assess functional capacity in a variety of patient populations. Space constraints often limit the practicality of the 6MWT according to the standard (2002) American Thoracic Society protocol, and therefore, adaptations to this protocol are common with potential implications for research and clinical practice. Furthermore, such implications for research and clinical practice may be augmented in low-resourced settings. OBJECTIVES: To determine the agreement between the 6 min walk distance (6MWD) achieved on the standard 30 m (6MWT30), and a straight 10 m (6MWT10), or 10 m figure-of-eight (6MWTF8) configuration, respectively. METHODS: A cross-sectional study was conducted in a socioeconomic challenged community. A heterogeneous sample of adults (n = 27) with non-communicable disease were randomized into performing the 6MWT10 (n = 15) or 6MWTF8 (n = 12), in addition to the standard 6MWT30. Pairwise comparison and concordance correlation coefficients were used to assess agreement. RESULTS: The mean (SD) 6MWD30 was 437(42) meters, while the mean 6MWD10 was 371(57). The mean difference (SE; p-value) between the 6MWD30 and 6MWD10 was 67 m (8.6; p .01). The mean 6MWD30 was 424(67) meters, while the mean 6MWDF8 was 347(58). The mean difference between the 6MWD30 and 6MWDF8 was 77 m (6.0; p .01). Moderate concordance was found between the 6MWT30 and 6MWTF8 or 6MWD10, respectively. CONCLUSIONS: The present data suggest that, independent of configuration, using a shorter pathway significantly reduced the 6MWD. Low-resource settings may benefit from contemporary measures of functional capacity more conducive to resource constraints, or standardization of the test when used in such settings.

The "trial within cohort design" was a pragmatic model for low-resourced settings.

OBJECTIVES: To determine the feasibility of using a trial within cohort (TWIC) design as a model to study pragmatic interventions in a low-resource setting to ensure that (i) ethical concerns raised with the conventional clinical trial design could be alleviated, (ii) key parameters could be obtained that may promote implementation of interventions in low-resource settings, although retaining the methodological rigor required to assess real-world efficacy. METHODS: A TWIC design was adopted to evaluate the feasibility of a community-based, patient-centered rehabilitation program, in an underprivileged South African community. Procedural aspects of the trial in relation to recruitment, retention, acceptance, and methodological rigor were evaluated. RESULTS: A total of 74 eligible participants, 36% of those who were identified as potential participants, agreed to participate and were randomized. Acceptance of the intervention (56%) was in line with previous research, and no reports of cross-contamination were received. Key lessons were learnt in the conduct of a TWIC design in low-resource settings, among others, related to blinding of the assessor, missing data, timing of recruitment, and various resource constraints. CONCLUSION: The findings of this study support further exploration for the use of this design in low-resource settings, particularly in settings where the conventional randomized clinical trial is ethically challenging or where detailed information on nonacceptance is paramount.

Data on the clinical, functional, and patient-reported outcomes of patient-centred rehabilitation for patients with non-communicable disease living in low-resourced settings.

In this data article, we present data obtained from a randomized clinical trial aimed at determining the feasibility of patient-centred rehabilitation for people with non-communicable disease (NCD) living in a low-resource setting. Patients were identified at primary care level and considered eligible if having on or more of the NCDs central to the NCD burden of disease (Cardiovascular Disease, Diabetes, Pulmonary Disease or Cancer). Using a "trial within cohort" design, a total 74 patients were included (36% of those identified as eligible) in a longitudinal cohort with repeated assessments at baseline, 8 and 16 weeks. A subset of 50 participants were randomly selected and offered to participate in a 6-week exercise and education-based, minimalistic, community-based rehabilitation program tailored to the low-resource context. The exercise component included aerobic and resistance exercise, as well as thematic empowerment aimed at improving exercise self-efficacy. The education component was aimed at improving general health literacy. Data was collected in terms of feasibility parameters (e.g., uptake, adherence), patient-demographics (e.g., age, gender), medical demographics (e.g., disease burden, multimorbidity), functional capacity measures (e.g., 6-minute Walk Test), and patient-reported outcomes (e.g., health-related quality of life). The data presented can give a basis for further clinical research in this field.

Persistent Symptoms among Frontline Health Workers Post-Acute COVID-19 Infection.

Growing evidence shows that a significant number of patients with COVID-19 experience persistent symptoms, also known as long COVID-19. We sought to identify persistent symptoms of COVID-19 in frontline workers at Right to Care South Africa, who are past the acute phase of illness, using a cross-sectional survey. We analysed data from 207 eligible COVID-19 positive frontline workers who participated in a two-month post-COVID-19 online self-administered survey. The survey response rate was 30%; of the 62 respondents with a median age of 33.5 years (IQR= 30-44 years), 47 (76%) were females. The majority (n = 55; 88.7%) self-isolated and 7 (11.3%) were admitted to hospital at the time of diagnosis. The most common comorbid condition reported was hypertension, particularly among workers aged 45-55 years. The most reported persistent symptoms were characterised by fatigue, anxiety, difficulty sleeping, chest pain, muscle pain, and brain fog. Long COVID-19 is a serious phenomenon, of which much is still unknown, including its causes, how common it is especially in non-hospitalised healthcare workers, and how to treat it. Given the rise in COVID-19 cases, the prevalence of long COVID-19 is likely to be substantial; thus, the need for rehabilitation programs targeted at each persistent COVID-19 symptom is critical.

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice.

OBJECTIVE: To facilitate knowledge synthesis and implementation of evidence supporting early physical activity and mobilization of adult patients in the intensive care unit and its translation into practice, we developed an evidence-based clinical management algorithm. METHODS: Twenty-eight draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n = 7) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus - semi-interquartile range <0.5 - were collated into the algorithm. RESULTS: The draft algorithm statements were edited and six additional statements were formulated. The 34 statements related to assessment and treatment were grouped into three categories. Category A included statements for unconscious critically ill patients; Category B included statements for stable and cooperative critically ill patients, and Category C included statements related to stable patients with prolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algorithm statements, only 50% (17/34) of the statements were rated essential. CONCLUSION: The evidence-based clinical management algorithm developed through an established Delphi process of consensus by an international inter-professional panel provides the clinician with a synthesis of current evidence and clinical expert opinion. This framework can be used to facilitate clinical decision making within the context of a given patient. The next step is to determine the clinical utility of this working algorithm.

Six-minute walk test protocol variations in low-resource settings - A scoping review.

BACKGROUND: The 6-min walk test (6MWT) is a validated tool, of submaximal intensity, used to objectively measure functional exercise capacity. In 2002, the American Thoracic Society (ATS) developed guidelines on standardising the implementation of the 6MWT. Despite the relative ease of conducting the 6MWT as per these guidelines, adaptations are implemented. OBJECTIVES: Identify (1) what 6MWT adaptations to the ATS guidelines have been described in low-resource settings (LRS), (2) the purpose of the adapted 6MWT and (3) the reported argumentation for making these adaptations in relation to the specific context. METHODS: Five databases were searched from inception until February 2021. Studies that adapted and conducted the 6MWT in LRS were included. Data concerning the study source, participants, 6MWT: purpose, variations, outcome and rationale were extracted. RESULTS: A total of 24 studies were included. The majority of studies (n = 18; 75%) were conducted in lower-middle income countries. The most common adaptation implemented was variation to course length. Eight studies provided a rationale for adapting the 6MWT. Space constraint was the most common reason for adaptation. CONCLUSION: The most common reason (space constraints) for adapting the 6MWT in LRS was addressed through adaptations in course length and/or configuration. The results of this review suggest that the value of the ATS-guided 6MWT in LRS may need to be re-evaluated. CLINICAL IMPLICATIONS: Using adapted forms of the 6MWT may lead to an underestimation of a patient's abilities, misinformed discharge and developing inappropriate exercise programmes. Additionally, diverting from ATS guidelines may affect the continuity of care.

Unravelling 'low-resource settings': a systematic scoping review with qualitative content analysis.

INTRODUCTION: The effects of healthcare-related inequalities are most evident in low-resource settings. Such settings are often not explicitly defined, and umbrella terms which are easier to operationalise, such as 'low-to-middle-income countries' or 'developing countries', are often used. Without a deeper understanding of context, such proxies are pregnant with assumptions, insinuate homogeneity that is unsupported and hamper knowledge translation between settings. METHODS: A systematic scoping review was undertaken to start unravelling the term 'low-resource setting'. PubMed, Africa-Wide, Web of Science and Scopus were searched (24 June 2019), dating back ≤5 years, using terms related to 'low-resource setting' and 'rehabilitation'. Rehabilitation was chosen as a methodological vehicle due to its holistic nature (eg, multidisciplinary, relevance across burden of disease, and throughout continuum of care) and expertise within the research team. Qualitative content analysis through an inductive approach was used. RESULTS: A total of 410 codes were derived from 48 unique articles within the field of rehabilitation, grouped into 63 content categories, and identified nine major themes relating to the term 'low-resource setting'. Themes that emerged relate to (1) financial pressure, (2) suboptimal healthcare service delivery, (3) underdeveloped infrastructure, (4) paucity of knowledge, (5) research challenges and considerations, (6) restricted social resources, (7) geographical and environmental factors, (8) human resource limitations and (9) the influence of beliefs and practices. CONCLUSION: The emerging themes may assist with (1) the groundwork needed to unravel 'low-resource settings' in health-related research, (2) moving away from assumptive umbrella terms like 'low-to-middle-income countries' or 'low/middle-income countries' and (3) promoting effective knowledge transfer between settings.

Patient-Reported OUtcome measures in key African languages to promote Diversity in research and clinical practice (PROUD)-protocol for a systematic review of measurement properties.

INTRODUCTION: Sub-Saharan Africa is a subcontinent with a proud cultural richness and diversity, yet inexplicably also a region with severe health care challenges and inequity. To challenge this health equity gap and reduce the burden of disease, the patient's voice in monitoring and evaluation of health and health care interventions is paramount. The aim of this two-phased review is to map the availability of patient-reported outcome measures (PROMs) in a selection of non-English, African Languages, and systematically evaluate the measurement properties of the PROMs that were identified. METHODS: This systematic review will be conducted in two phases. In phase 1, we will scope the literature for patient-reported outcome measures (PROMs), either developed from scratch or through translation and validation in a sub-Saharan African country and a selection of non-English, African languages (n = 31; spoken in > 10 million people and/or a national language). The availability of PROMs will be mapped against the previously reported burden of disease in the respective countries included. Subsequently, in phase 2, we systematically evaluate the measurement properties of these PROMs using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for systematic reviews on PROMs. To ensure rigour, secondary searches will be developed to specifically locate articles that report on the measurement properties of the PROMs identified during phase 1. The evidence will be graded using the modified GRADE approach. DISCUSSION: This review will provide a comprehensive overview and quality appraisal of PROMs developed in non-English, African languages. Consequently, this review when concluded may be an important first step in promoting access to these PROMs for use in clinical practice and research, as well as facilitate identification and prioritization of key knowledge gaps.

Health education interventions to promote health literacy in adults with selected non-communicable diseases living in low-to-middle income countries: A systematic review and meta-analysis.

RATIONALE, AIMS AND OBJECTIVES: Health illiteracy is an important contributor to the burden of non-communicable diseases (NCDs); in particular in settings where health illiteracy is part of a perpetuating system of risk factors. Interventions that promote health literacy may provide an important tool in the primary and secondary prevention of NCDs. The objective of this systematic review was to evaluate the effectiveness of health literacy interventions on health literacy in the management of patients with selected NCDs living in low-to-middle income countries (LMIC). METHODS: Seven electronic databases were searched (October 29, 2020) for RCTs aimed at improving health literacy in adults with NCDs in LMICs. Eligible NCDs included those pertaining to cancer, cardiovascular disease (CVD), chronic respiratory disease (CRD) or Diabetes. Studies were included that explicitly focussed on improving health literacy, and reported comprehensive measures of health literacy, or components thereof (ie, knowledge, attitude or behaviour). Random-effect meta-analyses were conducted for continuous outcome measures (Hedges-g). RESULTS: The completed search yielded 2573 unique results of which 53 unique studies met the inclusion criteria. Studies included patients with cancer (n = 1, 2%), CRD (n = 8, 15%), CVD (n = 11, 21%) or Diabetes (n = 33, 62%). A significant (P < .01) summary effect was found for disease knowledge (SES = 1.27 [n = 23, 95%CI = 1.05-1.49]), attitude (SES = 1.17 [n = 20, 95%CI = 0.88-1.47]), and behaviour (SES = 1.20 [n = 31, 95%CI = 0.94-1.46]). CONCLUSIONS: These results support the conclusion that there is compelling evidence, in particular, for patients with Diabetes, that health-literacy interventions are effective in promoting disease knowledge, attitude and behaviour across four chronic conditions that drive the burden of NCDs.

Training for Transformation: Opportunities and Challenges for Health Workforce Sustainability in Developing a Remote Clinical Training Platform.

Background: In 2018, Stellenbosch University's Ukwanda Centre for Rural Health led a faculty initiative to expand undergraduate health professions training to a new site, 9 hours drive from the health sciences campus in the sparsely populated Northern Cape Province of South Africa in the town of Upington. This is part of a faculty strategy to extend undergraduate health sciences training into an under-resourced part of the country, where there is no medical school. During 2019, the first year of implementation, four final year medical students undertook a longitudinal integrated clerkship at this site, while final year students from other programmes undertook short 5-week rotations, with plans for extending rotations and including more disciplines in 2020. The aim of this study was to understand stakeholder perceptions regarding the development of Upington as a rural clinical training site and how this influenced existing services, workforce sustainability and health professions education. Methods: An iterative thematic analysis of qualitative data collected from 55 participants between January and November 2019 was conducted as part of the case study. A constructivist approach to data collection was utilized to explore participants' perceptions, experiences and understanding of the new training site. Triangulation of data collection and reflexive thematic analysis contributed to the trustworthiness of the data and credibility of the findings. Findings: The perceptions of three key groups of stakeholders are reported: (1) Dr. Harry Surtie Hospital and Academic Programme Managers; (2) Supervising and non-supervising clinical staff and (3) Students from three undergraduate programs of the Faculty. Five themes emerged regarding the development of the site. The themes include the process of development; the influence on the health service; workforce sustainability; a change in perspective and equipping a future workforce. Discussion: This case study provides data to support the value of establishing a rural clinical training platform in a resource constrained environment. The influence of the expansion initiative on the current workforce speaks to the potential for improved capacity and competence in patient management with an impact on encouraging a rural oriented workforce. Using this case study to explore how the establishment of a new rural clinical training site is perceived to influence rural workforce sustainability and pathways, may have relevance to other institutions in similar settings. The degree of sustainability of the clinical training initiative is explored.