A Qualitative Exploratory Study: Using Medical Students' Experiences to Review the Role of a Rural Clinical Attachment in KwaZulu-Natal

Objectives: There are challenges when it is considered that a main role of a rural clinical attachment for medical students is to encourage students to return after graduation to practise in rural areas. This view may lead to the relative neglect of other potential valuable roles with regard to rural exposure. This paper draws on the Force Field Model of teacher development to describe medical students' experiences; illustrate the complexity of interacting factors during rural exposure; caution that experiences cannot be predicted and highlight the positive incentives of a rural clinical attachment. Design: The design was explorative; descriptive and qualitative. Setting: The study setting was a district hospital in rural KwaZulu-Natal. Subjects: The participants were four final-year medical students who had completed a compulsory attachment during their Family Medicine rotation. Results: The participants felt that overall the experience was positive. The effect of biography and contextual forces were not as strong as expected. Institutional forces were important and programmatic forces tended to have a negative effect on experiences. The participants particularly enjoyed being acknowledged and felt empathy for the difficult tasks of doctors

Dilemmas of Telling Bad News: Paediatric Palliative Care Providers' Experiences in Rural KwaZulu-Natal; South Africa

Background. In general; the principles of palliative care suggest that; at some stage; patients should be given 'bad news' about poor illness prognosis. The information is often important for care planning; especially when it involves disclosure to children. Although there are ongoing debates about whether to tell or not to tell children bad news; these debates have largely been informed by patients who live in a developed-world context. In contrast; this paper focuses on telling bad news to children and their families from a rural; developing-world context.Objective. The objective was to analyse the experiences of providers of palliative care to children when they attempted to fulfil one of their roles as palliative caregivers; i.e. to prepare patients and families for a child's poor illness prognosis. Method. This was an exploratory study that was approached qualitatively. Five nurses and eight home-based care workers who provided palliative care for children in rural areas of South Africa formed a purposive; information-rich; self-selected sample. Data were produced through discussions with participants; using photographs taken by the caregivers to stimulate and contextualise the discussions.Results. Participants experienced four dilemmas with regard to telling bad news: when families did not want to be told any bad news; when participants felt uncomfortable about telling bad news; when participants and patients shared dissimilar values about telling bad news; and when participants were unsure about when to tell bad news.Conclusion. In the rural areas where the study was conducted; children are not usually given bad news about their illness. Disclosing poor prognosis led to the dilemmas faced by caregivers. The result was that the emotionally charged work of caring for children reaching the end of their lives became more challenging for the caregivers because they were not prepared for cultural complexities. In view of the findings of this study; there is a need for ongoing research into paediatric palliative caregiving in context

Exploration of Pain in Children on Antiretroviral Treatment in a Regional Hospital in South Africa

Background: Patients with human immunodeficiency virus (HIV) disease on antiretroviral therapy (ART) may experience pain for a variety of reasons; including the effects of the virus itself; associated opportunistic infections and the ART. Studies indicate that pain in adults on ART is frequent; can be severe; and is often undertreated. This study sought to explore the experience; and the prevalence of pain in young children aged 3-13 years on ART.Method: Primary caregivers of children aged 3-13 years on ART attending a paediatric ART clinic at a regional hospital in Durban participated in the study. Convenience sampling was used. The Wong-Baker FACEST Pain Rating Scale and a questionnaire adapted from Hirshefeld were used to investigate variables such as age; cluster of differentiation 4 (CD4) count; ART regimen; ART duration; and site; prevalence and impact of pain during activities. Data were analysed using a standard statistical programme.Results: Four hundred and twenty primary caregivers were interviewed. Most were mothers caring for their HIV-positive children; and the majority of the children were aged 3-7 years. Most children were on a first-line ART regimen; and half reported pain. Nociceptive pain (visceral or somatic) was the most common type of pain; and pain interfered with the daily activities of a third of the children. There was a significant association between CD4 count and pain (p-value = 0.040). Paracetamol was the most commonly used analgesic.Conclusion: Pain was a common problem; and generally was undertreated with analgesia. A need to improve pain assessment and management in this population group was identified

Factors that positively influence adherence to antiretroviral therapy by HIV and/or AIDS patients and their caregivers

Background: The importance of dedicated adherence to antiretroviral treatment (ART) in the management of Human Immunodeficiency Virus (HIV) is well documented. Multiple factors may affect adherence and this study explores patients' and their caregivers' perceptions of factors which may positively influence adherence to ART. Method: This study was a descriptive, qualitative study that used both free attitude interviews and focus-group discussions. Nineteen patients attending a busy ART-clinic at a district hospital in KwaZulu-Natal and eight caregivers were purposefully selected. Selection criteria included good adherence to ARTs as evidenced by excellent clinic attendance for more than one year with evidence of clinical, immunological and viral improvement. Interviews were tape recorded, transcribed and thematically analysed. Results: Ten female participants, nine male participants and eight caregivers took part in the study. Participants highlighted three main categories that positively affect their adherence to ART namely: patient, disease and health care provider-related factors. Sub-themes included issues related to acceptance, disclosure to significant others, symptomatic improvement on ARTs and the importance of supportive relationships. Participants greatly valued the health care provider relationship and felt that the main role of the health care provider was to educate and support. Conclusion: This study has shown that the factors which most influenced adherence were patient-related (acceptance, disclosure, determination, and family support), disease-related and treatment-related (symptomatic illness and improvement on ARTs), and healthcare worker-related (relationships, and adherence classes)