Strengths and challenges of community-based clinical training as viewed by academics at the University of KwaZulu-Natal, Durban, South Africa

Background. Community-based education (CBE) is seen as a valuable tool in transforming health professions education by aligning clinical training with graduate competencies and needs of the health system. However, academics involved in the implementation have varied views.Objectives. To explore the experiences and views of academics involved in community-based training in the College of Health Sciences at the University of KwaZulu-Natal, Durban, South Africa. Methods. This qualitative study used interviews and focus group discussions consisting of a purposively selected sample of academics. The interviews were audio taped, transcribed and analysed using thematic analysis.Results. Three main themes emerged from the data analysis: the strengths of CBE, challenges experienced in implementation and academics' suggestions concerning challenges. The strengths included benefits to the institution, students, health system and communities. The main challenges experienced were insufficient support from the institution and the Department of Health (DoH). Suggestions were made by academics to overcome these challenges.Conclusion. The study indicates that CBE is perceived as an important pedagogical approach in transforming health professions education, as it can align clinical training with the business plan of the university and the needs of the health system. However, for the successful implementation of CBE, full support from the university and the DoH is required

The Costs of Delivering Human Papillomavirus Vaccination to Grade 4 Learners in KwaZulu-Natal; South Africa

BACKGROUND:The national human papillomavirus (HPV) vaccination roll-out in South Africa provides two doses of Cervarix to all female Grade 4 learners in state schools. This study estimated the costs of vaccinating all learners in KwaZulu-Natal Province (females or males and females) using either the two- or three-dose strategies for both the bivalent and quadrivalent vaccines.OBJECTIVE:To determine costs of the HPV vaccination programme in KwaZulu-Natal.METHODS:Costs were determined adapting World Health Organization vaccination costing guidelines. RESULTS:The 2014 current cost of delivering three doses of Gardasil was ZAR510 per learner. The projected cost of delivering Cervarix to female learners at two or three doses over the period 2014 - 2018; adjusted for inflation; was ZAR172 717 342 and ZAR250 048 426; respectively. Similarly; the cost for Gardasil at these doses was ZAR197 482 200 and ZAR287 194 361; respectively. For male and female learners the cost for Cervarix over this period at two or three doses was ZAR337 101 132 and ZAR540 150 713; respectively. Similarly; the cost for Gardasil at these doses was ZAR426 597 971 and ZAR620 392 784; respectively. Accounting for population variation for females over 5 years; the cost of two doses of Cervarix ranged from ZAR168 888 677 to ZAR 176 545 977 at the lower and upper 95% confidence intervals (CIs); respectively. For three doses the cost ranged from ZAR244 505 544 to ZAR255 591 263 at the lower and upper 95% CIs; respectively. Similarly; the cost for two doses of Gardasil ranged from ZAR193 104 566 to ZAR201 859 798. For three doses the cost ranged from ZAR280 828 057 to ZAR293 560 614. CONCLUSION:This study gives decision makers a basis for structured planning and cost apportionment to ensure effective roll-out of the HPV vaccination programme

Review of the Cardiovascular Safety of COXIBs Compared to NSAIDS : Review Article

There is no doubt that NSAiDs and CoXiBS are the mainstay for managing pain and inflammation in arthritis. overall; at therapeutically equivalent doses; both NSAiDs and CoXiBs provide equivalent analgesic and anti-inflammatory efficacy. However; the gastrointestinal risk associated with NSAiDs is considerable. More recently; the cardiovascular risk associated with NSAiDs and CoXiBs has become a concern. Most patients; particularly the young; can benefit from NSAiDs without the risk of serious adverse gastrointestinal or cardiovascular events. However; patients with a previous history of serious gastrointestinal complications and the elderly; who could be at risk; do require alternatives. CoXiBs have significant benefits over NSAiDs in reducing the incidence of serious gastrointestinal complications (perforations; ulcers and gastric bleeding). Currently two oral CoXiBs are available; celecoxib and lumiracoxib; and one parenteral CoXiB; parecoxib. Celecoxib has been on the market for longer and has the largest body of evidence. The older NSAiDs; such as meloxicam; with preferential CoX-2 inhibition do not have good long-term evidence of reducing the incidence of serious gastrointestinal complications. However; these agents do have evidence of tolerability; ie; reducing the less-serious gastrointestinal effects; mainly dyspepsia. The South African Rheumatoid Arthritis Association's guidelines; amended in November 2005 recommend CoXiBs for elderly patients ( 60 years) with previous gastropathy and those on warfarin and / or corticosteroids; providing they do not have contra-indications. However; caution is advised when prescribing CoXiBs for patients with risk factors for heart disease. These recommendations are very similar to those made by the National institute for Clinical Excellence (NiCE). in addition; it should be noted that for those patients without any cardiovascular complications but with gastrointestinal risk factors or on aspirin; it may be necessary to add a proton pump inhibitor (PPi). PPis; however; provide little benefit for bleeding and ulceration of the lower intestine. one consequence of this low-grade bleeding is anaemia and a general feeling of malaise in patients with rheumatic disease. Current evidence suggests that CoXiBs such as rofecoxib and celecoxib do not increase small intestinal permeability and that celecoxib does not cause lower intestinal bleeding and may be of benefit to those patients with lower gastrointestinal complications. In patients at risk for cardiovascular complications; both NSAiDs and CoXiBs have been shown to increase the risk of myocardial infarctions (Mi); hypertension and heart failure. Studies comparing CoXiBs and non-specific NSAiDs should; however; be interpreted with caution. one needs to take into account the underlying baseline cardiovascular risk of the populations being compared. CoXiBs appear to be prescribed preferentially to patients who were at an increased risk of cardiovascular events compared with patients prescribed non-specific NSAiDs. When the overall risk of cardiovascular complications is relatively low and an anti-inflammatory agent is required; choice because of its lower cardiovascular toxicity potential compared to NSAiDs and other CoXiBs