Comparing in-person, blended and virtual training interventions; a real-world evaluation of HIV capacity building programs in 16 countries in sub-Saharan Africa.

We sought to evaluate the impact of transitioning a multi-country HIV training program from in-person to online by comparing digital training approaches implemented during the pandemic with in-person approaches employed before COVID-19. We evaluated mean changes in pre-and post-course knowledge scores and self-reported confidence scores for learners who participated in (1) in-person workshops (between October 2019 and March 2020), (2) entirely asynchronous, Virtual Workshops [VW] (between May 2021 and January 2022), and (3) a blended Online Course [OC] (between May 2021 and January 2022) across 16 SSA countries. Learning objectives and evaluation tools were the same for all three groups. Across 16 SSA countries, 3023 participants enrolled in the in-person course, 2193 learners participated in the virtual workshop, and 527 in the online course. The proportions of women who participated in the VW and OC were greater than the proportion who participated in the in-person course (60.1% and 63.6%, p<0.001). Nursing and midwives constituted the largest learner group overall (1145 [37.9%] vs. 949 [43.3%] vs. 107 [20.5%]). Across all domains of HIV knowledge and self-perceived confidence, there was a mean increase between pre- and post-course assessments, regardless of how training was delivered. The greatest percent increase in knowledge scores was among those participating in the in-person course compared to VW or OC formats (13.6% increase vs. 6.0% and 7.6%, p<0.001). Gains in self-reported confidence were greater among learners who participated in the in-person course compared to VW or OC formats, regardless of training level (p<0.001) or professional cadre (p<0.001). In this multi-country capacity HIV training program, in-person, online synchronous, and blended synchronous/asynchronous strategies were effective means of training learners from diverse clinical settings. Online learning approaches facilitated participation from more women and more diverse cadres. However, gains in knowledge and clinical confidence were greater among those participating in in-person learning programs.

Core competencies required by toxicology graduates in order to function effectively in a Poisons Information Centre: A Delphi study.

INTRODUCTION: The availability of trained Medical Toxicologists in developing countries is limited and education in Medical Toxicology remains inadequate. The lack of toxicology services contributes to a knowledge gap in the management of poisonings. A need existed to investigate the core competencies required by toxicology graduates to effectively operate in a Poisons Information Centre. The aim of this study was to obtain consensus from an expert group of health care workers on these core competencies. This was done by making use of the Delphi technique. METHODOLOGY: The Delphi survey started with a set of carefully selected questions drawn from various sources including a literature review and exploration of existing curricula. To capture the collective opinion of experts in South Africa, Africa and also globally, three different groups were invited to participate in the study. To build and manage the questionnaire, the secure Research Electronic Data Capture (REDCap) web platform was used. RESULTS: A total of 134 competencies were selected for the three rounds and in the end consensus was reached on 118 (88%) items. Panel members agreed that 113 (96%) of these items should be incorporated in a Medical Toxicology curriculum and five (4%) should be excluded. DISCUSSION: All participants agreed that effective communication is an essential skill for toxicology graduates. The curriculum can address this problem by including effective pedagogy to enhance oral and written communication skills.Feedback from panellists indicated that the questionnaires were country-specific and not necessarily representative of all geographical locations. This is an example of the 'battle of curriculum design' where the context in which the curriculum will be used, will determine the content. CONCLUSION: The Delphi method, based on three iterative rounds and feedback from experts, was effective in reaching consensus on the learning outcomes of a Medical Toxicology curriculum. The study results will ultimately improve education in Medical Toxicology.

A peer evaluation of the community-based education programme for medical students at the University of Zimbabwe College of Health Sciences: A southern African Medical Education Partnership Initiative (MEPI) collaboration

Background. The University of Zimbabwe College of Health Sciences (UZCHS), Harare, which has a long tradition of community-based education (CBE), has not been evaluated since 1991. An innovative approach was used to evaluate the programme during 2015.Objectives. To evaluate the CBE programme, using a peer-review model of evaluation and simultaneously introducing and orientating participating colleagues from other medical schools in southern Africa to this review process.Methods. An international team of medical educators, convened through the Medical Education Partnership Initiative, worked collaboratively to modify an existing peer-review assessment method. Data collection took the form of pre-visit surveys, on-site and field-visit interviews with key informants, a review of supporting documentation and a post-review visit.Results. All 5 years of the medical education curriculum at UZCHS included some form of CBE that ranged from community exposure in the 1st year to district hospital-based clinical rotations during the clinical years. Several strengths, including the diversity of community-based activities and the availability of a large teaching platform, were identified. However, despite the expression of satisfaction with the programme, the majority of students indicated that they do not plan to work in rural areas in Zimbabwe. Several key recommendations were offered, central to which was strengthening the academic co-ordination of the programme and curriculum renewal in the context of the overall MB ChB curriculum.Conclusion. This evaluation demonstrated the value of peer review to bring a multidimensional, objective assessment to a CBE programme

Strengthening Rural Health Placements for Medical Students: Lessons for South Africa from International Experience

BACKGROUND:This article derives lessons from international experience of innovative rural health placements for medical students. It provides pointers for strengthening South African undergraduate rural health programmes in support of the government's rural health; primary healthcare and National Health Insurance strategies.METHODS:The article draws on a review of the literature on 39 training programmes around the world; and the experiential knowledge of 28 local and international experts consulted through a structured workshop.RESULTS:There is a range of models for rural health placements: some offer only limited exposure to rural settings; while others offer immersion experiences to students. Factors facilitating successful rural health placements include faculty champions who drive rural programmes and persuade faculties to embrace a rural mission; preferential selection of students with a rural background; positioning rural placements within a broader rural curriculum; creating rural training centres; the active nurturing of rural service staff; assigning students to mentors; the involvement of communities; and adapting rural programmes to the local context. Common obstacles include difficulties with student selection; negative social attitudes towards rural health; shortages of teaching staff; a sense of isolation experienced by rural students and staff; and difficulties with programme evaluation.CONCLUSIONS:Faculties seeking to expand rural placements should locate their vision within new health system developments; start off small and create voluntary rural tracks; apply preferential admission for rural students; set up a rural training centre; find practical ways of working with communities; and evaluate the educational and clinical achievements of rural health placements

Rural district hospitals - essential cogs in the district health system - and primary healthcare re-engineering.

The re-engineering of primary healthcare (PHC) is regarded as an essential precursor to the implementation of National Health Insurance in South Africa, but improvements in the provision of PHC services have been patchy. The authors contend that the role of well- functioning rural district hospitals as a hub from which PHC services can be most efficiently managed has been underestimated, and that the management of district hospitals and PHC clinics need to be co-located at the level of the rural district hospital, to allow for proper integration of care and effective healthcare provision.

Transforming rural health systems through clinical academic leadership: lessons from South Africa.

CONTEXT: Under-resourced and poorly managed rural health systems challenge the achievement of universal health coverage, and require innovative strategies worldwide to attract healthcare staff to rural areas. One such strategy is rural health training programs for health professionals. In addition, clinical leadership (for all categories of health professional) is a recognised prerequisite for substantial improvements in the quality of care in rural settings. ISSUE: Rural health training programs have been slow to develop in low- and middle-income countries (LMICs); and the impact of clinical leadership is under-researched in such settings. A 2012 conference in South Africa, with expert input from South Africa, Canada and Australia, discussed these issues and produced recommendations for change that will also be relevant in other LMICs. The two underpinning principles were that: rural clinical leadership (both academic and non-academic) is essential to developing and expanding rural training programs and improving care in LMICs; and leadership can be learned and should be taught. LESSONS LEARNED: The three main sets of recommendations focused on supporting local rural clinical academic leaders; training health professionals for leadership roles in rural settings; and advancing the clinical academic leadership agenda through advocacy and research. By adopting the detailed recommendations, South Africa and other LMICs could energise management strategies, improve quality of care in rural settings and impact positively on rural health outcomes.

Educational factors that influence the urban-rural distribution of health professionals in South Africa: a case-control study.

SETTING: The influence of undergraduate and postgraduate training on health professionals' career choices in favour of rural and underserved communities has not been clearly demonstrated in resource-constrained settings. OBJECTIVES: This study aimed to evaluate the influence of educational factors on the choice of rural or urban sites of practice of health professionals in South Africa. METHODS: Responses to a questionnaire on undergraduate and postgraduate educational experiences by 174 medical practitioners in rural public practice were compared with those from 142 urban public hospital doctors. Outcomes measured included specific undergraduate and postgraduate educational experiences, and non-educational factors such as family and community influences that were likely to affect the choice of the site of practice. RESULTS: Compared with urban doctors, rural respondents were significantly less experienced, more likely to be black, and felt significantly more accountable to the community that they served. They were more than twice as likely as the urban group to have been exposed to rural situations during their undergraduate training, and were also five times more likely than urban respondents to state that exposure to rural practice as an undergraduate had influenced their choice of where they practise. Urban respondents were significantly more attracted to working where they do by professional development and postgraduate education opportunities and family factors than the rural group. CONCLUSIONS: Evidence is provided that rural exposure influences the choice of practice site by health professionals in a developing country context, but the precise curricular elements that have the most effect deserve further research.

The consequences upon patient care of moving Brits Hospital: a case study.

BACKGROUND: In 2001, North West Province took the decision to increase bed capacity at Brits Hospital from 66 beds to 267 beds. After careful consideration of costs and an assessment of available land, it was decided to demolish the existing hospital and rebuild the new hospital on the same site. It was planned that during this time that clinical services would be moved to a temporary makeshift hospital and to primary health care clinics. This case study documents the consequences of this decision to move services to the makeshift hospital and how these challenges were dealt with. METHODS: A cross-sectional descriptive study was undertaken. Ten key members of staff at management and service delivery level, in the hospital and the district, were interviewed. Key documents, reports, correspondence, hospital statistics and minutes of meetings related to the move were analysed. RESULTS: The plan had several unforeseen consequences with serious effects on patient care. Maternity services were particularly affected. Maternity beds decreased from 30 beds in the former hospital to 4 beds in the makeshift hospital. As numbers of deliveries did not greatly decrease, this resulted in severe overcrowding, making monitoring and care difficult. Perinatal mortality rates doubled after the move. An increase in maternal deaths was noted. The lack of inpatient ward space resulted in severe overcrowding in Casualty. The lack of X-ray facilities necessitated patients being referred to a facility 72 km away, which often caused a delay of 3 days before management was completed. After-hours X-rays were done in a private facility, adding to unforeseen costs. Although the initial plan was for the makeshift hospital to stabilise and refer most patients, referral routes were not agreed upon or put in writing, and no extra transportation resources were allocated. The pharmacy had insufficient space for storage of medication. In spite of all these issues, relationships and capacity at clinics were strengthened, but not sufficiently to meet the need. DISCUSSION: Hospital revitalisation requires detailed planning so that services are not disrupted. Several case studies have highlighted the planning necessary when services are to be moved temporarily. Makeshift hospitals have been used when renovating or building hospitals. During war or disasters, plans have been made to decant patients from one facility to another. From the Brits case study, it would appear that not enough detailed planning for the move was done initially. This observation includes failure to appreciate the interrelatedness of systems and the practicality of the proposal, and to budget for the move and not just the new structure. CONCLUSION: The current service offered at the makeshift hospital at Brits is not adequate and has resulted in poor patient care. It is the result of a planning process that did not examine the consequences of the move, both logistic and financial, in adequate detail. Committed hospital staff have tried their best to offer good care in difficult circumstances.

Evaluation of the parallel rural community curriculum at flinders university of south Australia: lessons learnt for Africa

Objectives. To review data collected during an evaluation of the Flinders University Parallel Rural Community Curriculum (PRCC) in order to reflect on its relevance for medical education in Africa.Setting. The PRCC offers a community-based longitudinal curriculum as an alternative for students in their pre-final year of medical training. Design. Individual and focus group interviews were conducted with students; staff; health service managers; preceptors and community members. Results. Students are exposed to comprehensive; holistic; relationship-based care of patients; with a graded increase in responsibility. Students have varying experience at different sites; yet achieve the same outcomes. There is a strong partnership with the health service.Conclusions. The principle of balancing sound education and exposure to a variety of contexts; including longitudinal community-based attachments; deserves consideration by medical educators in Africa

An Approach to Clinical Problem Solving for Primary Health Care Student Nurses

The article provides a description of a method of teaching a clinical problem-solving process to primary health care nurses/clinical nurse practitioners (PHC nurses). The process was developed in the Soweto PHC Nurse Training Unit over the past 30 years as a result of the changing availability and role of nurse and doctor teaching staff. Students doing the diploma for nurse clinicians (Diploma in Clinical Nursing Science; Health Assessment; Treatment and Care) are guided in the use of mind maps; assisted by constant clinical practice and group discussions to develop their clinical problem-solving process. This method has assisted in clinical training

Understanding Participation in a Hospital-Based HIV Support Group in Limpopo Province; South Africa

Background: Support groups are an appropriate way of delivering psychosocial support to people living with HIV/AIDS; especially in low-resource countries. The aim of the study was to understand why people with HIV attended psychosocial support groups. Methods: This was a qualitative study design using focus-group discussions in which support-group members volunteered to participate. Five focus groups were involved in the study. Results: The participants attended because they were referred by a health-care worker; wanted information; wanted emotional support; accompanied an ill relative or knew about the support group. Perceived benefits included receiving psychological support; accepting one's HIV status; reducing stigma and isolation; increasing hope; forging new friendships; helping others; obtaining HIV-related information; developing strategies to change behaviour; gaining access to medical care at the adjoining HIV clinic and receiving food donations. Negative aspects of attending the support group included the large size of the support group; long queues at the HIV clinic; concerns about confidentiality and negative staff attitudes towards the participants. Leaders were concerned about conflict; burn-out and impractical protocols. Access to disability grants was also a concern. Conclusions: Support groups can assist members to cope with the various challenges associated with living with HIV/ AIDS through offering structured emotional; informational; instrumental and material support. Support group sizes should be limited. A structured curriculum containing up-to-date information about ART should also be offered to support groups. Social workers should furthermore be involved to facilitate access to appropriate social grants. Finally; support group leaders should receive appropriate training and regular debriefing

Exposure to Primary Healthcare for Medical Students: Experiences of Final-Year Medical Students

Introduction: Recognising the importance of primary healthcare in the achievement of the 1997 White Paper for the Transformation of the Health System and the Millennium Development Goals; the Faculty of Health Sciences of the University of the Witwatersrand introduced an integrated primary care (IPC) block. In a six-week final year preceptorship; medical students are placed in primary healthcare centres in rural and underserved areas. This article describes the experiences of medical students during their six weeks in the IPC block. Methods: The study was qualitative; based on data collected from the logbooks completed by the students during the IPC rotation. A total of 192 students were placed in 10 health centres in the North West and Gauteng provinces in the 2006 academic year. These centres included district hospitals; clinics and NGO community health centres. Results: The students reported that the practical experience enhanced their skills in handling patients in primary care settings. They developed an appreciation of primary healthcare as a holistic approach to healthcare. The students attained increased levels of confidence in handling undifferentiated patients; and became more aware of community health needs and problems in health service delivery. Conclusions: Exposure to the IPC block provided a valuable experience for final-year students; as it is critical for orienting students to the importance of primary healthcare; which is essential for the realisation of targets identified in the national health policy

Rural-origin health science students at South African universities.

BACKGROUND: Rural areas in all countries suffer from a shortage of health care professionals. In South Africa, the shortage is particularly marked; some rural areas have a doctor-to-population ratio of 5.5:100 000. Similar patterns apply to other health professionals. Increasing the proportion of rural-origin students in faculties of health sciences has been shown to be one way of addressing such shortages, as the students are more likely to work in rural areas after graduating. OBJECTIVE: To determine the proportion of rural-origin students at all medical schools in South Africa. DESIGN: A retrospective descriptive study was conducted in 2003. Lists of undergraduate students admitted from 1999 to 2002 for medicine, dentistry, physiotherapy and occupational therapy were obtained from 9 health science faculties. Origins of students were classified as city, town and rural by means of postal codes. The proportion of rural-origin students was determined and compared with the percentage of rural people in South Africa (46.3%). RESULTS: . Of the 7 358 students, 4 341 (59%) were from cities, 1 107 (15%) from towns and 1 910 (26%) from rural areas. The proportion of rural-origin students in the different courses nationally were: medicine--27.4%, physiotherapy--22.4%, occupational therapy--26.7%, and dentistry--24.8%. CONCLUSION: The proportion of rural-origin students in South Africa was considerably lower than the national rural population ratio. Strategies are needed to increase the number of rural-origin students in universities via preferential admission to alleviate the shortage of health professionals in rural areas.

Rural Origin Health Science Students in South African Universities

Background. Rural areas in all countries suffer from a shortage of health care professionals. In South Africa; the shortage is particularly marked; some rural areas have a doctor-topopulation ratio of 5.5:100 000. Similar patterns apply to other health professionals. Increasing the proportion of rural-origin students in faculties of health sciences has been shown to be one way of addressing such shortages; as the students are more likely to work in rural areas after graduating. Objective. To determine the proportion of rural- origin students at all medical schools in South Africa. Design. A retrospective descriptive study was conducted in 2003. Lists of undergraduate students admitted from 1999 to 2002 for medicine; dentistry; physiotherapy and occupational therapy were obtained from 9 health science faculties. Origins of students were classified as city; town and rural by means of postal codes. The proportion of rural-origin students was determined and compared with the percentage of rural people in South Africa (46.3). Results. Of the 7 358 students; 4 341 (59) were from cities; 1 107 (15) from towns and 1 910 (26) from rural areas. The proportion of rural-origin students in the different courses nationally were: medicine - 27.4; physiotherapy - 22.4; occupational therapy - 26.7; and dentistry - 24.8. Conclusion. The proportion of rural-origin students in South Africa was considerably lower than the national rural population ratio. Strategies are needed to increase the number of rural-origin students in universities via preferential admission to alleviate the shortage of health professionals in rural areas

Key issues in clinic functioning - a case study of two clinics.

OBJECTIVE: The aim of this research was to understand key issues in the functioning of two different primary care clinics serving the same community, in order to learn more about clinic management. DESIGN: An in-depth case study was conducted. A range of qualitative information was collected at both clinics. Data collected in the two clinics were compared, to gain an understanding of the important issues. SETTING: Data were collected in a government and an NGO clinic in North West province. SUBJECTS: This report presents the findings from patient and staff satisfaction surveys and in-depth individual interviews with senior staff. RESULTS: Key findings included the following: (i) there are attitudinal differences between the staff at the two clinics; (ii) the patients appreciate the services of both clinics, though they view them differently; (iii) clinic A provides a wider range of services to more people more often; (iv) clinic B presents a picture of quality of care, related to the environment and approach of staff; (v) waiting time is not as important as how patients are treated; (vi) medications are a crucial factor, in the minds of staff and patients; and (vii) a supportive, empowering organisational culture is needed to encourage staff to deliver better care to their patients. The management of the clinic is part of this culture. CONCLUSIONS: This research provides lessons regarding key issues in clinic functioning which can make a major difference to the way services are experienced. A respectful and caring approach to patients, and an organisational culture which supports and enables staff, can achieve much of this without any additional resources.

Influences on the choice of health professionals to practice in rural areas.

BACKGROUND: Training health care professionals (HCPs) to work in rural areas is a challenge for educationalists. This study aimed to understand how HCPs choose to work in rural areas and how education influences this. METHODS: Qualitative individual interviews were conducted with 15 HCPs working in rural areas in SA. RESULTS: Themes identified included personal, facilitating, contextual, staying and reinforcing factors. Personal attributes of the HCPs, namely rural origin and/or their value system, determine consideration of rural practice. The decision to 'go rural' is facilitated by exposure to rural practice during training, an understanding of rural needs and exposure to rural role models. Once practising in a rural area, the context and nature of work and the environment influence the decision to remain, supported by the role of family and friends, ongoing training and development, and the style of health service management. Personal motivation is reinforced by a positive relationship with the community, and by being an advocate and role model for the local community. Educational factors were often felt to work against the decision to practise in rural areas. DISCUSSION: The results show the complexity of the interaction between a large number of factors working together to make HCPs choose to go and stay in rural areas. Factors other than educational ones seem more important. A comprehensive approach is needed to attract and retain HCPs in rural areas. Issues for educationalists to address include helping rural-origin students to connect with their own values and communities.

Building consensus on clinical procedural skills for South African family medicine training using the Delphi technique

Background: The development of registrar training as part of the newly created speciality of family medicine in South Africa requires the development of a national consensus on the clinical procedural skills outcomes that should be expected of training programmes.Methods This study utilized a Delphi technique to establish a national consensus between 35 experts from training institutions; those already in family practice and managers who might be employing family physicians in both private and public sector contexts. Results: Consensus was reached on 214 core skills at different levels of desired competency and 23 elective skills. The core skills were divided into 58 that should be taught by family physicians; 101 that should be performed independently and 55 that should be performed during training under supervision. The panel were unable to reach consensus on a further 21 skills.ConclusionThis is the first study that has proposed a set of essential clinical procedural skills for the training of family physicians in South Africa. The findings will act as a benchmark for programmes in South Africa and through the new initiative of `FaMEC in Africa' may influence curriculum development in other African countries. They may be used as a guide for curriculum planning; as a way of monitoring skills development and as an indication to registrars of the skills they need to achieve for assessment purposes. The findings may also inform the planning of training programmes for the proposed mid-level health worker (clinical associate) in South Africa as their skills will be a sub-set of these skills and will be taught by family physicians within district hospitals. Training programmes for undergraduates and interns in family medicine may also want to position themselves as stepping stones in line with these final outcomes of postgraduate training

Building Consensus on Clinical Procedural Skills for South African Family Medicine Training Using the Delphi Technique

Background: The development of registrar training as part of the newly created speciality. Methods: This study utilized a Delphi technique to establish a national consensus between 35 experts from training institutions; those already in family practice and managers who might be employing family physicians in both private and public sector contexts of family medicine in South Africa requires the development of a national consensus on the clinical procedural skills outcomes that should be expected of training programmes.Results: Consensus was reached on 214 core skills at different levels of desired competency and 23 elective skills. The core skills were divided into 58 that should be taught by family physicians; 101 that should be performed independently and 55 that should be performed during training under supervision. The panel were unable to reach consensus on a further 21 skills.Conclusion: This is the first study that has proposed a set of essential clinical procedural skills for the training of family physicians in South Africa. The findings will act as a benchmark for programmes in South Africa and through the new initiative of 'FaMEC in Africa' may influence curriculum development in other African countries. They may be used as a guide for curriculum planning; as a way of monitoring skills development and as an indication to registrars of the skills they need to achieve for assessment purposes. The findings may also inform the planning of training programmes for the proposed mid-level health worker (clinical associate) in South Africa as their skills will be a sub-set of these skills and will be taught by family physicians within district hospitals. Training programmes for undergraduates and interns in family medicine may also want to position themselves as stepping stones in line with these final outcomes of postgraduate training